Presented  by 
Dr  Piggott 


COLLEGE  OF  OSTEOPATHIC  PHYSICIANS 
AND  SURGEONS  •  LOS  ANGELES,  CALIFORNIA 


^ 


If* 


/TABULAR  HANDBOOK 


AUSCULTATION  AND  PERCUSSION^ 


ano 


BV 

HERBMT  C.  dl\PP,  A.M.,  M.D. 

PROFESSOR   Of    DISEASES  i^JHE\CHEST    IN    THE    BOSTON    UNIVERSITY    SCHOOL  OF    MEDICINE,   AND 
ND   LUNGS    DEPARTMENT    OF  THE   COLLEGE   DISPENSARY. 


ITH  FOUR  PLATES. 


m  esse  meditia  sine  atisculttitione  et  percitssione." 

CORVISART. 


FIFTH     EDITIOK. 


BOSTON  AND   NEW  YORK : 
HOUGHTON,  MIFFLIN  AND  COMPANY. 
»tbtr)StlrE  ^rcs'i,  Camirttrge. 
1886. 


t>. 


u          C  58 


Copyright,  1878, 
BT  HERBERT   C.  CLAPP, 


RIVERSIDE,  CAMBRIDGE: 

ILECTROTYPED  AND  PRINTED   BY 

H.  0.  HOCGHTON  ANJ>  COMPANY. 


PREFACE. 


IN  the  preparation  of  this  little  book,  I  have  con- 
sulted the  works  and  compared  the  views  of  many 
who  have  been  eminent  in  the  physical  exploration 
of  the  chest,  such  as  Laennec,  Avenbrugger,  Corvi- 
sart,  Piorry,  Skoda,  Barth  and  Roger,  Walshe,  Hope, 
Stokes,  Fuller,  Grisolle,  Bennett,  Latham,  Flint,  Bal- 
four,  Hayclen,  Ziemssen,  Fothergill,  and  Loomis,  and 
here  desire  in  a  general  way  to  acknowledge  my  in- 
debtedness to  them,  as  it  has  seemed  impossible  to  do 
so  in  the  text  in  each  instance. 

Since  the  illustrious  Laennec  discovered  the  art  of 
auscultation  in  1816,  very  many  investigations  have 
been  made  and  much  has  been  written  on  the  sub- 
ject. While  on  the  one  hand  it  is  perfectly  surpris- 
ing how  little  the  master  mind  of  Laennec  left  to  be 
done,  and  how  many  of  his  descriptions,  classifications, 
and  meanings  of  sounds  still  remain  unimproved  upon 
in  spite  of  sharp  criticism,  yet  on  the  other  hand,  as 
would  naturally  be  expected,  other  experimenters 
since  have  discovered  new  facts,  and  by  a  wider  ex- 
perience have  been  able  to  point  out  more  or  less 
error  here  and  there  in  the  works  of  the  father  of 
auscultation.  I  have  endeavored  to  give,  arranged  in 
tabular  form,  a  condensed  summary  of  the  most  au- 
thentic observations  down  to  the  present  time. 


S'65 


iv  PREFACE. 

As  to  the  theories  of  the  mechanism  of  the  produc- 
tion of  some  of  the  sounds,  there  has  been  a  great 
deal  of  controversy,  in  which  Skoda  with  his  "  con- 
sonance "  and  "  tension  "  and  ojther  theories  has  taken 
quite  a  prominent  part.  Those  theories  have  been 
given  in  the  following  tables  which  seem  most  rational 
and  which  are  at  present  most  generally  accepted. 

In  the  nomenclature  of  the  physical  signs,  care  has 
been  taken  not  to  use  those  terms  which  merely  ex- 
press somebody's  theory  of  their  mode  of  production, 
Skoda's  "  consonating  rale,"  for  instance,  is  a  very 
ill-advised  term,  as  the  theory  of  consonance  is  far 
from  being  universally  accepted,  and  no  one  who  re- 
jects the  theory  would  like  to  use  such  a  term. 
Even  the  common  term  "  mucous  rale "  has  been 
made  to  give  place  to  the  much  more  expressive 
"  bubbling  rale^"  which  does  not  imply  that  it  is 
always  caused  by  mucus,  but  leaves  room  for  its  pro- 
duction sometimes  also  by  pus,  serum,  softened  tuber- 
cle, etc. 

To  avoid  confusion,  and  for  the  convenience  of 
those  who  may  have  become  familiar  with  some  par- 
ticular authority,  many  of  the  synonyms  have  been 
added  in  small  type  in  parentheses. 

In  determining  what  classification  to  follow,  it  has 
been  thought  desirable  to  avoid  the  excessive  and 
complicated  refinements  of  some  authors,  without,  on 
the  other  hand,  losing  sight  of  the  necessity  for  suffi- 
cient thoroughness. 

There  has  been  an  effort  to  make  the  arrangement 
of  material  in  the  following  tables  so  systematic,  that 
any  special  point  needing  investigation  can  be  imme- 
diately referred  to,  without  a  tedious  and  laborious 


PREFACE.  v 

search  through  many  pages  and  perhaps  many  vol- 
umes. The  condensed  tabular  arrangement  will  be 
found  especially  advantageous  also  in  differential  di- 
agnosis, as  it  brings  into  such  close  juxtaposition  in- 
formation which  is  usually  widely  scattered,  rendering 
•comparison  easy,  point  by  point. 

Studied  in  connection  with  Chapter  IV.  of  Da 
Oosta's  excellent  work  on  Diagnosis,  with  its  graphic 
descriptions  and  convenient,  helpful  diagrams,  these 
tables  will  probably  furnish  the  student  with  all  that 
is  really  necessary  in  the  majority  of  cases  coming 
under  observation.  If,  however,  he  desires  to  make 
a  special  study  of  the  subject,  he  is  referred  to  the 
two  large  and  valuable  treatises  on  the  "  Diseases 
of  the  Respiratory  Organs "  and  "  Diseases  of  the 
Heart,"  written  by  Dr.  Austin  Flint  of  New  York, 
who  is  probably  the  greatest  authority  on  the  phys- 
ical diagnosis  of  such  diseases  in  this  country,  and  to 
whom  I  desire  to  acknowledge  myself  especially  in- 
debted. It  should  be  remembered,  however,  that  the 
pathology  of  these  works  is  not  quite  up  to  date. 

It  is  also  hoped  that  this  handbook  may  be  found 
useful  by  physicians  in  active  practice.  It  is  hardly 
to  be  expected  that  practitioners  who  do  not  make  a 
specialty  of  lung  and  heart  diseases,  even  if  they 
have  at  some  time  carefully  studied  into  the  subject, 
and  have  been  well  posted,  can  retain  in  their  memories 
for 'immediate  use  at  all  times  every  point  necessary 
for  a  delicate  physical  diagnosis.  If  the  case  be  at 
all  obscure,  they  feel  the  necessity  of  consulting  some 
authority.  In  such  emergencies,  the  busy  doctor  may 
appreciate  such  a  time  and  labor  saving  contrivince 
as  the  present.  It  often  needs  only  a  word  here  and 
there  to  revive  memories  of  extensive  reading. 


vi  PREFACE. 

It  is  very  doubtful  if  at  this  late  day  any  well  edu- 
cated physician  could  be  found  to  despise  the  value 
of  auscultation  and  percussion  as  aids  to  diagnosis. 
Such  a  contempt  would  at  once  stamp  the  man  who 
showed  it  as  an  ignorant  pretender.  But  there  are 
many  who  do  not  feel  thoroughly  at  home  in  this 
branch,  and  on  account  of  too  slight  practical  ac- 
quaintance with  it,  and  lack  of  time  or  inclination 
for  a  laborious  research  into  its  theory,  prefer  to  trust 
for  the  most  part  to  the  symptoms  alone  rather  than 
to  the  uncertainties  (to  them)  of  physical  signs. 
Here  most  truly  "  a  little  knowledge  is  a  dangerous 
thing."  For  if  the  practitioner,  finding  jerking  res- 
piration, for  example,  in  a  given  case,  knows  that 
jerking  respiration  is  a  sign  of  phthisis,  and  does  not 
remember  that  it  may  be  a  sign  of  several  other  dis- 
eases too,  and  on  the  strength  of  this  sign  alone  diag- 
nosticates the  case  as  phthisis,  it  would,  indeed,  be  far 
better  for  him  to  have  known  nothing  whatever  of 
auscultation  and  percussion,  and  to  have  been  guided 
entirely  by  the  symptoms.  It  is  such  partial  knowl- 
edge, to  say  nothing  of  the  utter  ignorance  of  others, 
that  has  to  some  extent  brought  auscultation  and  per- 
cussion into  disrepute  in  certain  places. 

It  is  very  desirable  to  have  a  proper  appreciation 
of  the  comparative  value  of  physical  signs  and  symp- 
toms, without  enthusiastically  overestimating  either. 
He  who  trusts  to  symptoms  alone  for  his  diagnosis  of 
heart  and  lung  diseases  will  very,  very  often  be  led 
astray.  On  the  other  hand,  the  mistake  may  be  made 
in  the  opposite  direction  of  placing  too  exclusive  reli- 
ance on  physical  signs  alone.  In  fact,  they  must  be 
taken  together  and  complement  each  other.  If  they 


PREFACE.  vii 

are,  and  proper  attention  is  paid  to  the  history  of 
each  case,  and  also  to  its  well-known  pathological 
laws,  an  accurate  diagnosis  can  be  made  in  the  great 
majority  of  instances. 

When  speaking  of  heart  diseases,  Da  Costa  says : 
"  A  knowledge  of  the  physical  signs  is  the  solid 
foundation,  without  which  any  structure  that  may  be 
reared  will  soon  tumble  to  pieces." 

In  fact,  the  symptoms  of  heart  disease  are  compara- 
tively insignificant.  Quite  so  much  cannot  be  said  of 
the  comparative  value  of  signs  and  symptoms  in  lung 
diseases ;  but  even  here  the  great  importance  of  the 
former  is  attested  by  the  immense  strides  which  have 
been  made  in  the  diagnosis  of  such  affections  since 
the  discovery  of  the  present  methods  of  physical  ex- 
ploration, which  would  have  been  utterly  impossible 
before. 

The  plates  have  been  reproduced  (with  slight  alter- 
ations), by  the  "  direct  transfer "  process,  from  the 
"  Hand  bud  i  und  Atlas  der  topographischen  Percus- 
sion," by  Professor  Weil  of  Heidelberg,  published 
at  Leip/ig  in  1877. 

H.  C.  CLAPP. 

BOSTON,  ('••totx'r  3,  1878. 


CONTENTS. 


VAtt 

INTRODUCTION. xi 

PAET  I. 

TABLE  NO.  1. 

RESPIRATION  IN  HEALTH. 

Vesicular,  puerile,  senile,  and  tracheal  or  laryngeal         ....        20 

TABLE  NO.  2. 

RESPIRATION  IN  DISEASE.  (1.)  ABNORMAL  INTENSITY. 
Exaggerated,  feeble,  and  suppressed .22 

TABLE  NO.  3. 

RESPIRATION  IN  DISEASE.  (2.)  ABNORMAL  RHYTHM. 
Jerkiug  respiration  and  prolonged  expiration 24 

TABLE  NO.  4. 

RESPIRATION  IN  DISEASE.  (3.)  ABNORMAL  QUALITY  AND  PITCH. 
Bronchial,  broncho-vesicular,  cavernous,  and  amphoric    ....        26 

TABLE  NO.  5. 
RALKS. 

I.  Tracheal  and  laryngeal ;  dry  and  moist 30 

II.  Bronchial ;  dry  (sonorous  and  sibilant),  and  moist  (coarse  and  fine 

bubbling  and  subcrepitant)         .......  30 

III.  Vesicular ;  crepitant          •••......  34 

IV.  Cavernous ;  gurgling     .........  34 

TABLE  NO.  6. 

MORBID  PLEURAL  SOUNDS. 

Friction  sounds,  metallic  tinkling,  and  splashing 36 


X  CONTENTS. 

TABLE  NO.  7. 
THE  VOICE  IN  HEALTH. 

Tracheal  or  laryngeal  voice  and  whisper,  normal  thoracic  vocal  reso- 
nance and  fremitus,  and  normal  bronchial  whisper  ....  40 

TABLE  NO.  8. 
THE  VOICE  IN  DISEASE. 

Suppressed,  diminished,  and  increased  vocal  resonance  and  fremitus,  in- 
creased bronchial  whisper,  broncho  phony  and  whispering  bron- 
chophony,  cavernous  whisper,  amphoric  voice  and  whisper,  pec- 
toriloquy  and  whispering  pectoriloquy,  aegophony,  and  metallic  tink- 
ling   42 

TABLE  NO.  9. 
PERCUSSION  SIGNS. 

Normal  vesicular  resonance,  flatness,  dullness,  and  tympanitic,  exag- 
gerated, amphoric,  and  cracked-metal  resonance  46 

PART  II. 

TABLE  NO.  10. 
THE  PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  LUNGS. 

Acute  and  chronic  pleurisy,  empyema,  hydrothorax,  pulmonary  oedema, 
pneumo-hydrothorax,  pnoumothorax,  emphysema,  asthma,  bron- 
chitis, capillary  bronchitis,  plastic  bronchitis,  croupons  pneumonia, 
catarrhal  pneumonia,  chronic  pneumonia,  acute  miliary  tuberculo- 
sis, phthisis,  dilatation  of  bronchi,  carcinoma  of  lung,  and  intra-tho- 
racic  tumors,  especially  aneurism 54 

TABLE  NO.  11. 
THE  PHYSIC \L  DIAGNOSIS  OF  DISKASES  OF  THE  HEART. 

The  healthv  heart,  pericarditis,  emlocarditi-.  hypertrophy  of  the  left  and 
rierht  h"art«,  dilatation,  valvular  lesions  of  the  left  heart  (aortic  ob- 
struction and  rejruriritation.  and  mitral  obstruction  and  regurpita- 
tion).  and  of  the  risrht  heart  (pulmoni-  o!, ^motion  and  repurgita- 
tion,  and  tricn<pid  obstruction  and  re.u'U rjritation),  fatty  degenera- 
tion, and  cardiac  neuroses  ........  78 


INTRODUCTION. 


PATHOGNOMO^TIC  physical  signs  are  exceedingly 
rare.  It  is  not  true  that  each  disease  has  belonging 
to  it  one  or  more  individual  signs  like  labels,  which 
are  always  associated  with  it  and  no  other.  The  no- 
menclature of  diseases  is  not  so  rigidly  prescribed  by 
nature  as  it  would  be  in  such  a  case.  Physical  signs, 
instead  of  representing  individual  diseases,  represent 
merely  physical  conditions  which  may  be  common  to 
several  diseases.  For  instance,  dullness  on  percus- 
sion, bronchial  or  broncho-vesicular  respiration,  bron- 
chophony,  and  increased  vocal  fremitus  in  combina- 
tion would  indicate  solidification  of  the  lung,  but 
they  do  not  tell  us  on  what  the  solidification  depends. 
It  may  be  pneumonia,  it  may  be  phthisis,  it  may  be 
collapse  of  pulmonary  lobules,  it  may  be  lung  tissue 
compressed  by  a  pleuritic  exudation.  The  disease, 
the  particular  cause  of  the  solidification,  we  have  to 
reason  out  from  the  presence  or  absence  of  other 
physical  signs,  from  our  knowledge  of  pathology,  and 
from  the  history  and  symptoms  of  the  case. 

Before  beginning  the  study  of  auscultation  and  per- 
cussion, the  student  should  be  thoroughly  posted  in 
the  anatomy  and  physiology  of  the  organs  of  respira- 
tion and  circulation.  Then  naturally  follows  the  to- 
pography of  these  organs.  As  an  aid  in  constantly 


Xll  INTRODUCTION. 

keeping  before  the  mind  this  topography,  which  is  of 
very  great  importance,  especially  in  the  diagnosis  of 
heart  diseases,  the  plates  have  been  added  to  this  vol- 
ume, and  should  be  carefully  studied  and  often  re- 
ferred to.  The  details  of  pictorial  illustrations  are 
easier  for  most  persons  to  remember  than  long  verbal 
descriptions,  no  matter  how  accurate  they  may  be. 

For  convenience  in  localizing,  recording,  and  com- 
paring signs,  the  surface  of  the  chest  has  been  mapped 
out  into  anterior,  lateral,  and  posterior  regions,  right 
and  left,  as  follows  :  — 

ANTERIORLY  —  The  supra-clavicular  region,  extend- 
ing from  the  clavicle  upwards  a  distance  varying  from 
half  an  inch  to  an  inch  and  a  half;  clavicular,  the 
space  occupied  by  the  clavicle  ;  infra-clavicular,  be- 
tween the  clavicle  and  the  third  rib  ;  mammary,  be- 
tween the  third  and  sixth  ribs;  infra-mammary,  be- 
low the  sixth  rib ;  supra-sternal,  the  hollow  space 
above  the  sternum ;  superior-sternal,  under  the  ster- 
num above  the  third  rib  ;  inferior-sternal,  under  the 
sternum  below  the  third  rib. 

LATERALLY  —  The  axillary  region,  having  for  its 
lower  boundary  a  horizontal  extension  of  the  lower 
boundary  of  the  mammary  region  ;  infra-axillary,  be- 
low this  line. 

POSTERIORLY  — The  scapular  region,  the  space  oc- 
cupied by  the  scapula,  extending  also  to  a  homont'l 
line  drawn  through  its  lower  angle  ;  infra-sen fiitl'ir, 
below  this  line  to  the  twelfth  rib  ;  inter-scapular,  be- 
tween the  inner  margin  of  the  scapula  and  the  spinal 
column. 

It  is  very  essential  that  the  healtJnj  sounds  of  aus- 
cultation and  percussion  should  become  thoroughly 


INTRODUCTION.  xiii 

familiar  to  the  student  before  he  spends  much  time 
on  the  morbid  sounds.  And  yet,  there  is  a  constant 
tendency  to  hurry  over  and  neglect  the  former  for 
the  sake  of  getting  at  the  practical  work  of  the  lat- 
ter. No  one  would  undertake  to  tune  a  piano  without 
being  so  familiar  with  the  true  tones  that  he  could 
recognize  the  least  departure  from  them.  Very  often 
in  the  most  important  cases  brought  to  the  physician, 
where  there  is  the  greatest  desire  for  information,  as, 
for  example,  in  the  detection  of  the  very  beginnings 
of  phthisis,  the  deviations  from  the  normal  sounds  are 
so  slight  as  to  be  entirely  disregarded  by  those  who 
do  not  know  by  practice  exactly  what  the  normal 
sounds  in  the  different  regions  of  the  chest  ought  to 
be.  And  even  where  one  thinks  he  knows  this,  con- 
stant reference  to  the  healthy  standard  is  necessary. 

Auscultation  is  said  to  be  immediate  when  the  un- 
assisted ear  is  applied  to  the  chest  of  the  patient,  and 
mediate  when  a  stethoscope  is  used.  Both  methods 
are  in  use,  and  it  is  very  desirable  to  become  practi- 
cally familiar  with  each.  Some  physicians  think  that 
they  can  hear  as  well  with  the  unassisted  ear  as  with 
the  stethoscope  ;  but  the  great  majority  of  those  who 
have  much  to  do  with  auscultation  give  a  very  de- 
cided preference  to  that  instrument.  Those  who  have 
used  a  stethoscope  for  any  considerable  length  of 
time  very  seldom  like  to  give  it  up.  It  is  often  pref- 
ernble  on  grounds  of  delicacy  when  examining 'lady 
patients,  and  the  avoidance  of  too  close  contact  which 
it  insures  is  certainly  pleasanter  to  the  examiner, 
when  the  patient  happens  to  be  at  all  uncleanly. 
Besides,  it  can  be  applied  to  certain  places  (such  as 
the  hollow  over  the  clavicle,  for  instance)  to  which  it 


xiv  INTRODUCTION. 

is  difficult  or  impossible  to  adjust  the  ear.  With  it, 
also,  particular  sounds,  which  we  may  wish  to  locate 
definitely  and  to  hear  as  far  as  possible  unmixed  with 
others  (as,  for  instance,  valvular  murmurs),  can  be 
circumscribed.  With  Cammanns  double  or  binaural 
stethoscope,  which  is  the  best,  the  sounds  are  intensi- 
fied and  made  more  distinct,  and  some  are  rendered 
audible  which  would  be  inappreciable  to  the  unassisted 
ear.  At  first,  until  one  gets  accustomed  to  it  and 
learns  how  to  use  it,  there  is  a  disagreeable  humming 
or  buzzing  which  is  very  confusing,  but  this  soon 
passes  off.  The  pectoral  extremity  should  be  closely 
applied  with  moderate  pressure,  and  the  edges  should 
fit  the  skin  exactly  all  around,  not  being  tilted  up  at 
one  side  to  allow  the  air  to  enter.  The  room  should 
be  quiet  and  there  should  be  no  friction  between  the 
stethoscope  and  the  clothing.  Stiff  hair  on  the  chest 
tinder  the  instrument  often  occasions  a  sound  which 
might  be  confused  with  the  crepitant  rale.  Beginners 
almost  always  get  the  ear-pieces  in  the  wrong  way. 
They  should  follow  the  direction  of  the  auditory  canal. 
The  stethoscope  should  be  applied  to  the  bare  skin. 
When  the  unassisted  ear  is  used,  it  is  pleasante/  to 
have  over  the  chest  one  thickness  of  soft  cloth,  like 
the  undergarment,  or  a  towel.  When  an  accurate  ex- 
amination in  a  doubtful  case  is  desired,  it  is  utterly 
impossible  to  make  it  without  removing  the  most,  if 
not  all,  of  the  clothing  from  the  chest ;  and  the  man 
who,  in  such  a  case,  gives  two  or  three  raps,  puts  his 
head  down  over  a  stiffly  starched  shirt  or  creaking 
corsets  or  rustling  silk,  and  then  solemnly  and  oracu- 
larly pronounces  an  opinion,  is  generally  acting  igno- 
rantly  or  dishonestly  by  his  patient.  It  might  almost 


INTRODUCTION.  xv 

be  said  that  if  the  intra-thoracic  noises  are  all  so  loud 
that  they  can  be  heard  above  the  noise  which  the 
outside  clothing  makes,  it  is  not  of  very  much  im- 
portance to  the  diagnosis  that  they  be  heard  at  all, 
for  in  such  conditions  the  symptoms  are  generally 
enough.  The  great  danger  in  listening  through  all 
the  clothing  is  that  of  not  hearing  (or  mixing  up)  deli- 
cate and  important  signs.  In  many  cases,  where  the 
problem  is  to  decide  whether  or  not  phthisis  is  pres- 
ent, it  is  sufficient  to  unbutton  the  upper  part  of  the 
clothing  and  turn  it  aside  so  as  to  expose  the  infra- 
clavicular  regions  for  examination,  as  phthisis  gener- 
ally attacks  these  regions  first.  But  even  here,  if  no 
deposit  be  found,  particular  thoroughness  demands  a 
further  search. 

In  immediate  auscultation  it  is  advisable  to  close 
one  ear  with  the  finger  to  exclude  outside  noises, 
and  particularly  when  studying  vocal  phenomena.  In 
the  latter  case,  besides,  the  patient  should  turn  his 
head  to  one  side  and  put  his  hand  up  to  his  mouth  to 
prevent  the  auscultator's  confusing  his  voice  com- 
ing directly  from  the  mouth  with  the  vocal  resonance 
coming  through  the  chest.  The  auscultator  should 
also  avoid  stooping  over  too  much  when  listening,  as 
the  congestion  of  blood  caused  by  such  a  position 
dulls  somewha  t  the  acuteness  of  hearing.  Unless  too 
weak,  the  patient  is  best  examined  in  the  sitting  post- 
ure, with  his  arms  hanging  down  for  the  anterior 
portion  of  the  chest,  raised  and  crossed  over  his  head 
for  the  lateral  regions,  and  crossed  with  the  body  bent 
forwards  for  the  posterior  regions.  Generally  he  has 
to  be  instructed  to  breathe  harder  than  usual,  and  often 
has  to  be  shown  how  to  breathe  properly.  In  children 


xvi  INTRODUCTION. 

it  is  easy  to  judge  of  the  vocal  resonance  when  they 
cry.  Finally,  one  side  of  the  chest  should  be  con- 
stantly compared  with  the  other,  portion  by  portion. 

Percussion,  as  a  method  of  diagnosticating  disease, 
was  discovered  by  Avenbrugger,  whose  researches 
were  published  at  Vienna  in  1761.  They  attracted 
but  little  attention,  however,  until  Corvisart  fifty 
years  afterwards  translated  them  into  French  and  in- 
troduced the  practice  into  the  French  hospitals.  Per- 
cussion, like  auscultation,  is  both  immediate  and  medi- 
ate. The  immediate  (which  was  the  only  method 
known  to  Avenbrugger  and  Laennec),  where  the  chest 
was  struck  directly  by  the  fingers,  is  now  never  re- 
sorted to,  having  been  entirely  superseded  by  the 
invention  by  Piorry  of  mediate  percussion,  which 
interposes  some  solid  substance,  called  a  pleximeter, 
between  the  chest  and  the  percussing  agent.  For 
this  purpose,  little  plates  of  ivory  or  wood  with  han- 
dles have  been  used,  or  a  flat  piece  of  common  elastic 
India  rubber.  The  best  pleximeter,  however,  is  a 
tapering  cylinder  of  hard  rubber  or  gutta-percha 
about  two  inches  long,  flanging  at  each  end,  one  cir- 
cular end-piece  being  smaller  than  the  other  for  ap- 
plication to  the  intercostal  spaces  and  supra-clavicular 
regions,  the  body  of  the  cylinder  (which  is  applied 
to  the  chest  at  right  angles)  making  an  excellent 
handle.  The  best  percussor  is  a  little  hammer  with 
a  hard  rubber  rod  or  handle  which  can  be  detached 
from  the  head,  which  is  madje  of  brass  and  tipped 
with  soft  rubber.  Most  physicians  use  for  a  plexime- 
ter the  left  middle  or  forefinger,  with  its  palmar  sur- 
face applied  to  the  chest,  and  for  a  percussor  the  right 
middle  or  forefinger  (or  both  together),  bent  so  as  to 


INTRODUCTION.  xvii 

strike  at  a  right  angle.  Although  it  takes  considera- 
ble time  and  practice  to  become  really  expert  in  per- 
cussing with  the  fingers,  much  more  than  with  the 
instruments  just  described,  yet  everybody  should 
learn  this  method,  as  it  is  a  very  valuable  one,  and 
the  instruments  cannot  always  be  at  hand  to  be  de- 
pended upon.  Where  one  has  a  great  deal  of  per- 
cussing to  do,  however,  he  generally  prefers  the  in- 
struments, as  so  much  pounding  on  the  back  of  the 
finger  used  as  a  pleximeter  is  apt  to  make  it  sore. 
Besides,  the  instruments  bring  out  the  sounds  more 
distinctly,  especially  for  purposes  of  demonstration  to 
others. 

Unless  the  patient  is  really  obliged  to  lie  down,  he 
should  be  percussed  in  the  sitting  or  standing  posture, 
with  his  arms  placed  as  already  described  for  aus- 
cultation, the  examiner  being  directly  in  front.  The 
two  sides  should  be  percussed  at  the  same  stage  of 
respiration,  as  the  expanded^  lung  occupies  more  room, 
pushing  down  the  liver  and  spleen  and  pressing  more 
in  front  of  the  heart ;  the  difference  between  a  full 
inspiration  and  a  deep  expiration  being  very  consid- 
erable. 

Since  we  draw  our  inferences  as  to  the  condition 
of  the  lungs  from  the  comparative  sound  in  differ- 
ent parts  of  the  chest  rather  than  from  the  absolute 
sound,  this  varying  somewhat  in  different  individu- 
als, it  is  important  to  strike,  immediately  after  each 
other  and  with  the  same  force,  portions  on  one  side 
which  correspond  as  nearly  as  possible  to  portions 
on  the  other  side.  Four  or  five  raps  in  succession 
are  best,  and  should  be  quick  and  sharp  rather  than 
slow  and  heavy.  More  forcible  blows  are  required  to 


xvni  INTRODUCTION. 

elicit  the  sounds  of  deeply  seated  than  of  superficial 
portions.  The  finger  or  pleximeter  should  be  applied 
firmly  on  the  spot  to  be  examined,  and  with  precisely 
the  same  amount  of  firmness  on  the  corresponding 
spot  on  the  other  side. 

The  pressure  should  be  sufficient  to  condense  the 
soft  parts  on  the  outside  of  the  chest.  Percussion 
should  be  performed  by  a  movement  of  the  wrist 
alone,  the  arm  and  forearm  remaining  motionless.  It 
would  be  well  for  the  beginner  to  commence  by  per- 
cussing the  right  infra-clavicular  region  in  a  healthy 
subject,  and  to  contrast  the  vesicular  resonance  found 
here  with  the  flatness  of  the  liver.  Next  he  might 
try  to  bring  out  the  proper  sound  of  that  part  of  the 
liver  which  lies  underneath  the  lung.  After  becoming 
practically  familiar  with  all  the  sounds  in  the  different 
regions  in  health,  he  can  try,  as  a  final  test  of  his 
powers,  the  deep  cardiac  space.  If  he  can  bring  out 
the  sounds  of  that  satisfactorily,  he  may  consider  him- 
self proficient. 

Heart-sounds. — In  health  there  is  no  difficulty  in 
telling  by  auscultation  which  is  the  first  and  which 
the  second  sound  of  the  heart  by  the  rhythm  and 
the  distinctive  characters  of  the  two  sounds  at  the 
apex  and  base  ;  and  generally  it  is  easy  to  decide  the 
question  in  the  same  way  if  the  heart  is  diseased, 
when  it  is  desired  to  know  whether  a  murmur  is  sys- 
tolic, presystolic,  or  diastolic.  But  sometimes  it  is 
impossible  or  difficult  to  do  so.  In  such  cases,  if  the 
apex-beat  can  be  felt,  this  being  synchronous  with  the 
first  sound,  the  problem  is  at  once  solved.  If  it  can- 
not be  felt,  the  radial  pulse  will  settle  the  point,  or 
still  better  the  carotid,  which  is  more  nearly  synchro- 
nous with  the  first  sound  of  the  heart. 


1. 


~—     ct+v*** 

6CO'^6t^>c 


ff 


PART  I. 
PHYSICAL  SIGNS. 


20 


AUSCULTATION  AND  PERCUSSION. 


TABLE  NO.   1. 


VARIETIES. 

CHARACTER  OF  THE   SOUND. 

VESICULAR  RESPIRATION. 
(Pulmonary.) 

Inspiration. 
A  soft,  diffused  sound  of  a  breezy  character,  grad- 
ually developed  and  continuous.    Increased  in  in- 
tensity with  the  rapidity  and  force  of  respiration, 
and  prolonged  by  a  full  inspiration.     Low  pitch. 

Expiration. 
Not   vesicular,  but  feebly   blowing  in   quality. 
Pitch  lower  and  intmsity  much  lessthauin  inspi- 
ration.    Usually  not  more  than  one  fourth  the 
length  of  inspiration,  and  absent  in   about  one 
third  of  the  cases.    No  interval  between  inspira- 
tion and  expiration. 

PUERILE  RESPIRATION. 

The  same  quality,  pitch,  and  rhythm  as  the  (pul- 
monary) vesicular  murmur,  but  exaggerated  or 
intensified  in  degree. 

SENILE  RESPIRATION. 

The  same  as  the  vesicular  respiration,  except 
that  the  intensity  is  diminished  and  the  expiration 
relatively  more  developed  and  longer. 

TRACHEAL  OR  LARTNGEAL 
RESPIRATION. 

Inspiration. 
Tubular  in  quality,  loud,  dry,  and  hollow. 
High  pitch.    An  interval   between  inspiration 
and  expiration. 

Expiration. 
Tubular  in  quality.    Uniformly  present.     As 
long   as  the   inspiratory   sound,   and  generally 
longer.     More  intense  and  higher  in  pitch. 

AUSCULTATION  AND  PERCUSSION. 


21 


RESPIRATION  IN  HEALTH. 


HOW  PRODUCED. 

USUAL   SEAT. 

Inspiratory  Sound. 
1.  "By  vibrations  excited  in  the  in- 
ward   current   of    air   by    its  friction 
against  the  walls  of  the  air  passages. 
2.  By  the  obstacles  presented  by  the 
subdivision  of  the  bronchi  ;  "  and 
3.  By  the  forcible  separation  of  the 
walls  of  the  pulmonary  vesicles,  which 
after  the  previous  expiration  have  be- 
come more  or  less  adherent  on  account 
of  their  natural  moisture. 

Expiratory  Sound. 
Simply  "  by  the  vibrations  excited  in 
the  expired  air  by  its  friction  against 
the  walls  of  the  air-passages." 

All  parts  of  the  chest.  There  are 
variations  in  the  intensity  of  the  mur- 
mur in  the  different  regions  of  the  chest, 
there  being  more  in  the  infra-clavicular 
and  inter-scapular  and  in  the  axillary 
and  infra-axillary  regions  than  in  the 
mammary  and  infra-mammary  regions, 
and  least  of  all  in  the  scapular  region. 

Sometimes  there  is  r.lso  a  plight  disparity  be- 
tween the  two  sides,  in  which  case  the  vesicu- 
lar quality  is  more  marked  and  the  pitch  lower 
on  the  left  than  on  the  right  side,  in  the  latter 
there  being  a  slight  approach  to  the  character 
of  broncho-  vesicular  respiration  (Table  No. 
4),  i.  e.,  expiration  a  little  longer  with  higher 
pitch,  and  inspiration  a  little  shortened. 

The  greater  intensity  of  the  murmur 
is  owing  to  the  greater  freedom  of  the 
action  of  the  lungs  in  early  childhood. 

In  children,  in  all  parts  of  the  chest 
where  the  ordinary  vesicular  respira- 
tion is  audible. 

The  change  is  owing  to  the  attenua- 
tion of  the  walls  of  the  air-cells  in  aged 
persons. 

In  old  age,  in  all  parts  of  the  chest 
where  the  ordinary  vesicular  respira- 
tion is  audible. 

By  the  rush  of  air  through  a  tube  of 
considerable  diameter,  rough  and  irreg- 
ular on  its  internal  surface,  and  possess- 
ing sound-reflecting  properties.    "  The 
hiirher  pitch  of  the  expiratory  sound  is 
due  to  the  greater  contraction  of  the 
glottis  by  the  approximation  of  the  vo- 
cal chords  in  expiration." 

In  the  supra-sternal  region,  over  the 
trachea  and  larynx. 

22 


AUSCULTATION  AND  PERCUSSION. 


TABLE  NO.  2.  -  RESPIRATION  IN  DISEASE. 


VARIETIES. 

CHARACTER  OP  THE  SOUND. 

HOW  PRODUCED. 

Like  the   healthy  vesic- 

By the  excessive  action 

ular     murmur    in     pitch, 

of  certain  healthy  portions 

EXAGGERATED  RES- 
PIRATION. 

rhythm,  and    quality,  but 
intensified  in  degree.    Iden- 

of the  lungs,  set  up  to  sup- 
ply the  deficiency  of  res- 

tical in  character  with  the 

piration  in  other  portions, 

(Puerile,  supplementary, 
increased,  hypervesicu- 
lar.) 

puerile  respiration  of 
healthy  children. 

which    are    destroyed   or 
affected  by  disease. 

"  The  ordinary  vesicular 
murmur,    not    altered    in 
character,   hut   simply  di- 
minished in  intensity  and  du- 
ration." 

By  any  cause  which  in- 
terferes with  and  prevents 
the   full   inflation  of   the 
lungs.     Such  as  — 
1  .  An  obstruction  to  the 

passage  of  air  in  some  por- 

FEEBLE RESPIRA- 

tion of  the  air  tubes. 

TION. 

2.  An     obstruction    or 

over-distention  of  the  air 

(Diminished,  weak.) 

vesicles. 

3.    Some    restraint    on 

the     movements    of    the 

chest- 

g 

4.  The  respiratory  mur- 

mur  may    be  imperfectly 

transmitted    to    the    ear, 

owing  to  intervening  fluids, 

solids,  or  air. 

No  sound  is  heard. 

By  very  great  obstruc- 

SUPPRESSED RESPI- 

tion to  the  entrance  of  air, 

RATION. 

or  by  the  interposition  of 

fluid   or  air  in   the  cavity 

(Absent.) 

of  the  pleura,  preventing^ 

the    transmission    of    the 

sound. 

AUSCULTATION  AND  PERCUSSION. 


23 


ABNORMAL   INTENSITY. 


USUAL,  SEAT. 


DISEASES   INDICATED. 


Not  peculiar  to  any  portion  of  the 
chest,  and  not  diffused  generally 
throughout  both  sides  of  the  chest,  like 
the  healthy  puerile  breathing,  but 
limited  to  certain  spots  in  the  vicinity 
of  diseased  portions  of  the  lungs,  or 
heard  all  over  the  healthy  lung,  when  the 
other  is  diseased.  If  heard  all  over 
both  lungs,  it  is  to  be  regarded  merely 
as  an  individual  peculiarity  and  not 
as  a  sign  of  disease. 


Pleurisy. 

Pneumonia. 

Phthisis. 

Vesicular  emphysema. 

Apoplectic  effusion. 
Carcinoma. 
Spasmodic  asthma. 
Pneumothorax. 
Foreign  body  in  bronchus. 
Aneurismal  or  other  intra-thoracic  tumors 
pressing  on  certain  bronchi. 


Variable.  The  whole  or  a  part  of  a 
lung. 

Feeble  respiration,  occurring  in  so 
many  conditions,  becomes  of  diagnos- 
tic importance  only  when  associated 
•with  other  phenomena. 


1.  Croup  ;  oedema  or  spasm  of  the  glottis  ; 
inflammatory  exudations  in  the  larynx  ;  for- 
eign body  in  a  bronchus;  mucus,  serum,  blood, 
or  pus  in  bronchus ;  swelling  of  mucous  mem- 
brane in  bronchitis  ;  asthma ;  permanent  con- 
traction of  bronchi ;  tumors  pressing  on  bron- 
chi,  i.  e.,  aneurism  or  enlarged  lymphatic 
gland. 

2.  Phthisis,  pneumonia,   pulmonary  oede- 
ma, vesicular   emphysema,  extravasation    of 
blood. 

3.  Paralysis  of  costal   muscles  or  of  dia- 
phragm; general  debility;  permanent  contrac- 
tion after  chronic  pleurisy  ;  old  pleuritic  ad- 
hesions ;  deformity  of  chest ;  the  pain  of  acute 
pleurisy,   pneumonia,  intercostal  neuralgia, 
pleurodynia,   or  peritonitis  :  the  mechanical 
interference  of  ascites,  pregnancy,  and  abdom- 
inal tumors. 

4.  Pleuritic  effusion,  thick  layer  of  lymph 
on    pleura,  hydrothorax,   pneumo-hydrotho- 
rax,  tumors,  thick  layer  of  fat  on  outside  of 
chest. 


"  May  occur  in  any  portion  of  the 
chest,  but  always  limited  to  one  or  more 
parts,  and  usually  to  the  whole  or  some 
portion  of  one  lung  only." 


Same  diseases  as  feeble  respiration, 
with  this  difference,  thnt  it  indicates 
more  decided  anatomical  lesions.  Most 
commonly  observed  in  connection  with 
excessive  effusions  of  fluid  or  air  in  the 
pleura. 


AUSCULTATION  AND  PERCUSSION. 


TABLE  NO.  3.  — RESPIRATION  IN  DISEASE. 


VARIETIES. 


CHARACTER  OF  THE  SOUND. 


HOW    PRODUCED. 


JERKING 
RESPIRATION. 

(Interrupted,  wavy, 
cogged-wheel.) 


Both  sounds,  especially 
the  inspiratory,  instead  of 
being  even  and  continuous 
from  their  commencement 
to  their  close,  are  broken 
into  one,  two,  or  more  parts. 


1.  By  some  local  obstacle 
to  the  ingress  or  egress  of  air. 
Usually  the  pressure  of  tu- 
bercular or  other  deposit,  or 
the  presence  of  thick  mucus 
in  the  air  passages,  or  spasm 
of  a  tube. 

2.  By  nervousness  or  shrink- 
ing on  account  of  pam. 


PROLONGED 
EXPIRATION. 


The  rhythm  changed  so 
that  the  expiration  is'length- 
ened  absolutely  and  rela- 
tively to  the  inspiration, 
which  is  generally  short- 
ened. 


1.  When  the  air-cells  are 
over-distended  and  have  lost 
their  natural  elasticity  from 
this  distention  or  (2)  on  ac- 
count of  deposits  in  their 
walls,  the  air  has  difficulty  in 
making  its  escape.  This  dif- 
ficulty may  be  increased  in 
the  latter  case  by  the  promi- 
nences produced  by  the  de- 
posit on  the  interior  of  the 
final  bronchial  ramifications, 
these  prominences  opposing 
obstacles  to  the  rapid  egress 
of  air. 


AUSCULTATION  AND  PERCUSSION. 


25 


ABNORMAL  RHYTHM. 


USUAL   SEAT. 


DISEASES   INDICATED. 


1.  Limited   to  a  part  of  the  chest, 
usually  one  of  the  apices,  where  it  is 
of  more  clinical  significance  than  when 

2.  Generally  diffused  over  the  chest. 


1.  Incipient  phthisis. 
Circumscribed  bronchitis. 
Asthma. 

2.  Nervousness. 
Pleurisy. 
Plenrodynia. 
Intercostal  neuralgia. 

•    This  sound  is  occasionally  observed  even 
in  healthy  persons. 


1.  All  over  one  or  both  sides  of  "the 
chest,  especially  the  upper  parts. 

2.  In  the  infra-clavicular  region,  es- 
pecially on  the  left  side. 


1.  Emphysema 

(if  non-tubular  and  of  low  pitch). 

2.  Phthisis 

(if  tubular  and  of  high  pitch). 

Occasionally  heard  to  a  slight  extent  on 
the  right  side  of  the  healthy  chest. 


26 


AUSCULTATION  AND  PERCUSSION. 


.     TABLE    NO.    4.  —  RESPIRATION    IN    DISEASE. 


VARIETIES. 


CHARACTER  OF  THE    SOUND. 


HOW   PRODUCED. 


BRONCHIAL 
RESPIRATION. 

(Tubular.) 


Inspiration. 

Quality  tubular,  non- 
vesicular.  Intensity  vari- 
able, pitch  high.  Inspi- 
ratory  sound  shortened ; 
ends  before  end  of  inspi- 
ratory  act.  Rarely  ab- 
sent. Can  be  imitated  by 
blowing  through  a  tube 
formed  by  the  fingers  and 
palm  of  one  hand. 

Expiration. 

Quality  tubular.  Pro- 
longed; as  long  as  or 
longer  than  the  sound  of 
inspiration  and  more  in- 
tense. Pitch  still  higher. 
Rarely  absent. 


It  always  denotes  consid- 
erable or  complete  solidifica- 
tion of  pulmonary  substance, 
either  by  the  addition  of 
some  morbid  material  or  by 
compression.  This  involves 
suppression  of  the  vesicular 
murmur.  The  sound  pro- 
duced by  the  passage  of  air 
through  the  bronchi,  which 
in  health  is  stifled  by  the 
vesicular  murmur  and  ren- 
dered inaudible,  is  now  trans- 
mitted- to  the  ear  intensified 
by  the.  solidified  lung,  which 
is  a  better  sound-conductor 
than  the  healthy  lung. 


BRONCHO-VESICU- 
I.AR   RESPIRATION 

(Rude,  rough,  harsh, 

Yesiculo-bronchial,  tu- 

bulo- vesicular.) 


Inspiration. 

The  tubular  and  vesic- 
ular quality  combined  in 
varied  proportions,  and 
the  pitch  raised  in  pro- 
portion to  the  amount  of 
tubular  quality.  Dura- 
tion frequently  shortened 
at  the  end.  Intensity  va- 
riable. Sometimes  ab- 
sent. 

Expiration. 

Prolonged.  Generally 
more  intense  than  inspi- 
ration. Pitch  higher  than 
in  inspiration.  Quality 
according  to  quality  in  in- 
spiration. Sometimes  ab- 
sent. 


Being  a  combination,  in 
varied  proportions,  of  the 
bronchial  and  vesicular  res- 
piration, it  is  produced  by 
the  same  cause  as  the  pre- 
ceding, although  not  to  the 
same  extent ;  the  amount  of 
solidification  not  being  suf- 
ficient to  extinguish  all  vesic- 
ular murmur. 


AUSCULTATION  AND  PERCUSSION. 


ABNOKMAL  QUALITY  AND  PITCH. 


USUAL   SEAT. 


DISEASES   INDICATED. 


In  phthisis  and  pleurisy  generally 
in  the  upper  part  of  the  chest.  In 
pneumonia  generally  the  lower  part 
behind,  especially  on  the  right  side. 
In  other  cases  variable. 

Being  identical  with  the  healthy  "  Tracheal 
Respiration,"  it  may  be  studied  in  the  supra- 
eternal  region  of  a  sound  person. 


Pneumonia. 
Phthisis. 
Pleuritic  effusion. 

Collapse  of  pulmonary  lobules. 

Pulmonary  oedema. 

Pulmonary  apoplexy. 

Carcinoma. 

Hydrothorax. 

Hy  dro  -pericardium . 

Aneurism  and  other  tumors. 


Same  as  the  preceding.  A  very 
important  sign  in  the  diagnosis  of  in- 
cipient phthisis. 


Same  diseases  as  the  preceding, 
only  indicating  a  lesser  amount  of  solid- 
ification. In  the  resolution  of  acute 
lohar  pneumonia  (croupous),  all  vari- 
eties of  the  sound  may  be  heard  by 
daily  auscultation,  from  that  which 
verges  on  the  bronchial  in  complete 
solidification,  to  th;it  which  verges  on 
the  vesicular,  which  conies  with  re- 
covery. 


28 


AUSCULTATION  AND  PERCUSSION. 


TABLE  NO.  4,  Continued.  —  RESPIKATION  IN  DISEASE. 


VARIETIES. 


CHARACTER  OF  THE  SOUND. 


HOW  PRODUCED. 


CAVERNOUS 
RESPIRATION. 


Inspiration. 

Quality  blowing  simply ; 
non-vesicular,  non-tubu- 
lar. Often  mixed  with 
gurgling.  (Table  No.  5.) 

Expiration. 

Quality  blowing.  Low- 
er pitch  than  inspiration. 
May  be  absent.  Often 
mixed  with  gurgling. 

Some  recognize  also  a  bron- 
cho -  cavernous  respiration, 
which,  as  its  name  signifies, 
is  a  combination  in  varied 
proportions  of  this  and  the 
bronchial  respiration. 


Produced  by  the  passage 
of  air  into  and  from  a  cav- 
ity with^ZomW  walls. 

Absent  when  the  cavity  is 
filled  with  liquid,  or  when 
the  tubes  leading  to  it  are 
obstructed.  If  deep-seated, 
and  beneath  solidified  lung, 
it  may  be  drowned  out  by  the 
loud  bronchial  respiration. 
R&les  also  may  obscure  it. 

It  can  be  imitated  by  blow- 
ing into  a  cavity  formed  by 
the  two  hands. 


AMPHORIC 
RESPIRATION. 


A  kind  of  musical  in- 
tonation like  the  sound 
produced  by  blowing 
upon  the  open  mouth  of 
a  decanter  or  phial.  It 
may  accompany  either 
inspiration  or  expiration 
or  both.  It  may  be  hum- 
ming and  of  low  pitch  or 
decidedly  ringing  and 
metallic. 


Not  caused,  like  cavernous 
respiration, "  by  the  free  circu- 
lation of  air  within  a  cavity, 
but  by  the  current  of  air  in 
the  bronchial  tubes  acting 
upon  the  air  contained  within 
a  cavity."  The  cavity  must 
have  more  or  less  rigid  walls, 
which  do  not  collapse  with 
expiration;  it  must  be  of 
considerable  size,  partially  or 
entirely  free  from  liquid  con- 
tents ;  there  must  be  an  un- 
obstructed communication 
(or  merely  a  very  thin  sep- 
tum) between  a  bronchial 
tube  and  the  cavity,  and  the 
perforation  must  be  above 
the  level  of  the  liquid,  if 
there  be  any  liquid. 


AUSCULTATION  AND  PERCUSSION. 


29 


ABNORMAL  QUALITY  AND  PITCH,  Continued. 


USUAL   SEAT. 


Heard  over  a  circumscribed  area, 
corresponding  to  the  size  of  the  cavity. 

Being  vastly  more  common  m 
phthisis  than  in  other  diseases,  its 
seat  is  generally  at  the  summit  of  the 
chest. 


DISEASES   INDICATED. 


Phthisis. 

Rarely  in 

Pulmonary  abscess. 
Gangrene. 
Cancer. 
Bronchial  dilatation. 


Generally  confined  to  a  circum- 
scribed space,  but  is  sometimes  dif- 
fused more  or  less  over  the  chest. 


Almost  pathognomonic  of  pnen- 
mo-hydrothorax  with  pulmonary  fis- 
tula. Sometimes  in  phthisis. 

Still  more  rarely  in  abscess,  etc. 


30 


AUSCULTATION  AND  PERCUSSION. 


TABLE   NO.  5. 


VARIETIES. 

CHARACTER  OF  THE  SOUND. 

RELATION    TO   INSPIRATION 
AND   EXPIRATION. 

I.  TRACHEAL 

AND 

LARYNGEAL 
RALES. 

Whistling,  wheezing,  crow- 
ing, whooping,  etc.  Most 
of  them  are  heard  without 
special  auscultation  and  at  a 
distance. 

Mostly  with    inspiration. 
Sometimes  with  both. 

a.   Dry  or  vibrat- 
ing. 

b.  Moist  or  bub- 
bling. 

Bubbling  sounds,  often 
called  "  death-rattles." 

With  both. 

II.  Bronchial 
Kales. 

Low-pitched,  musical  sounds, 
compared  to  snoring,  cooing, 
buz/ing,  grunting,  humming, 
a  note  of  a  bass-viol,  etc. 

With  both  or  either,  es- 
pecially with  expiration. 

a.  Dry  or  vibrat- 
ing. 

<1.)  SONOROUS 
RALES. 

nVa>frJ 

(2.)  SIBILANT 
RALES. 

High-pitched,  whistling, 
hissing,  or  clicking  sounds  of 
variable  intensity  and  dura- 
tion and  irregular  recur- 
rence. Often  compared  to 
shrill  musical  tones,  the  cries 
of  young  animals,  the  chirp- 
ing of  birds,  whistling  of 
wind  through  a  keyhole,  etc. 
Heard  with  the  respiratory 
murmur,  or  the  latter  may 
be  masked.  Loudest  in  asth- 

With both  or  either,   es- 
pecially with  inspiration. 

•  ft 

ma. 

Kl 


AUSCULTATION  AND  PERCUSSION. 


31 


EALES  (Rhonchi). 


HOW  PRODUCED. 

USUAL  SEAT. 

DISEASES  INDICATED. 

1.  By    contraction    at 

Larynx  and  trachea. 

1.   Laryngismus    stridu- 

the  glottis  from  spasm, 

These  sounds  are  often 

lus. 

eedema,     exudation      of 

propagated  through  the 

Pertussis. 

lymph,  etc. 

bronchial      tubes      and 

Croup. 

2.   By    diminution    of 

heard  in  the  chest,  where 

calibre  of  tube  below  the 

they  may,  in  a  few  cases, 

2.  Pressure  of  a  tumor. 

glottis. 

be  thought  to  originate. 

Morbid  growths  or  depos- 

Auscultation     of      the 
larynx  and  trachea  will 
at  once  settle  the  point. 

its. 
Cicatrization  of  ulcers. 
Paralysis      of      laryngeal 
muscles. 

By  the  passage  of  air 

Larynx  and  trachea. 

The  moribund  state. 

through  mucus  or  other 

Coma.    , 

liquid  in  the  tube. 

Inability  to  expectorate. 

"  By  the  vibrations  ex- 

Constantly   liable    to 

1.  Asthma. 

cited   by  the  passage  of 

change    position.      May 

Bronchitis. 

air    through    the    larger 

sometimes  disappear  af- 

2. Circumscribed  bron- 

bronchi, irregularly    nar- 

ter coughing.     They  are 

chitis      occurring     with 

rowed,    either    by    spas- 

either — 

pneumonia  or  phthisis. 

modic  contraction  of  their 

1.  More  or  less  diffused 

circular     fibres,"  or     by 

over  the  whole  chest  ;  or, 

swelling  of  their  mucous 

2.  Confined  to  one  side 

membrane,  or  by  the  ad- 

of the  chest,  or  limited 

hesion  of  viscid  mucus  to 

to  a  circumscribed  space. 

their    walls,    or    by   the 

(In  phthisis  the  circum- 

pressure of  a  tumor. 

scribed   space  is  gener- 

ally at  the  summit  of  the 

- 

chest.) 

Produced  in  the  same 

Same      as      sonorous 

Same  diseases  as  the 

manner,  but  in  the  smaller 

rales,   with  which   they 

sonorous  rales,  and  indi- 

bronchial tubes. 

are  frequently  mingled. 

cating   that   the  smaller 

tubes  are  affected. 

32  AUSCULTATION  AND  PERCUSSION. 

TABLE   NO.  5,  Continued. 


VARIETIES. 

CHARACTER  OF  THE   SOUND. 

RELATION    TO    INSPIRATION 
AND   EXPIRATION. 

A  coarse  bubbling  sound, 

With  either  or  both. 

conveying  the  impression  of 

the  bursting   of   bubbles  of 

b.  Moist  or  bub- 

somewhat   large   size.     The 

bling. 

"  death-rattles  "  are   an  ex- 

aggerated type  of  them.    If 
any  solidification  of  the  lung 

(1.)  COARSE  BUB- 

exists around   the  tubes  in 

BLING  RALES. 

which  the  sound  is  produced, 

the  pitch  is  raised  in  propor- 

(Coarse mucous 

tion  to  the  amount. 

rales.) 

(2.)  FINE  BUB- 
BLING RALES. 

(Pine  mucous  rales.) 

The  same  quality  of  sound, 
but  the  bubbles  are  smaller. 
The    coarse    and  .fine  bub- 
bling rales  may  be  imitated 
by  blowing  into  a   tumbler 
of  water   through  different 

With  either  or  both. 

sized  tubes. 

(3.)    SUBCREPI- 

The  same  quality,  but  the 
bubbles   are  very  small  in- 

With either  or  both. 
When    with    inspiration, 

TANT  RALES. 

deed.     Still,  they  are  some- 

near the  beginning. 

what  unequal  in  size,  as  in 

the     other      moist      rales. 

Slowly  evolved. 

AUSCULTATION  AND  PERCUSSION.  33 

RALES,  Continued. 


HOW   PRODUCED. 

USUAL  SEAT. 

DISEASES    INDICATED. 

By  the  bubbling  of  air 
through  liquid  (mucus, 
]iiis.  softened  tubercle, 
blood,  or  serum),  in  the 
larger  bronchial  tubes. 
Bubbling  rales,  both 
coarse  and  line,  are  very 
often  called  mucous  rales. 
This  term  is  not  so  ap- 
propriate, as  the  liquid 
by  means  of  which  they 
are  produced  is  not  al- 
ways mucus.  Unless 
specified,  when  "  bubbling 
rales  "  are  mentioned, 
bronchial  and  not  tra- 
cheal  are  understood. 

Constantly    liable    to 
change     position,    espe- 
cially   after    expectora- 
tion   or   coughing,    and 
not  occurring  with  every 
respiration. 
They  are  either  — 
1.  More   or  less    dif- 
fused   over    the    whole 
chest,  especially  the  in- 
fra-scapular regions,  or 
2.  Confined  to  one  side 
of  the  chest,  or  limited 
to  a  circumscribed  space. 
(In  phthisis  the  circum- 
scribed space  is  generally 
the  summit  of  the  chest.  ) 

1.  Bronchitis. 
2.  Circumscribed  bron- 
chiiis,     occurring     with 
phthisis  or  pneumonia. 
Softened  tubercle,  etc., 
in  tubes  in  phthisis,  blood 
in  haemoptysis  or  pulmo- 
nary apoplexy,  serum  in 
oedema,   pus    in    pulmo- 
nary or  hepatic  abscess. 

Produced  in  the  same 
manner  in  the  smaller 
bronchial  tubes. 

Same  as  coarse  bub- 
bling rales,  with  which 
they  are  frequently  min- 
gled. 

Same  as  coarse  bub- 
bling rales,  but  smaller 
tubes  affected. 

Produced  in  the  same 
manner  in  the  very  mi- 
nute bronchial  ramifica- 
tions. 

Same  as  coarse  bub- 
bling rales,  excepting 
that  they  are  very  much 
less  liable  to  change  po- 
sition. 

1  .  Capillary  bronchitis. 
Pulmonary  oedema. 
2.  Lobar      pneumonia 
during  resolution. 
Incipient  phthisis. 

34  AUSCULTATION  AND  PERCUSSION. 

TABLE  NO.  5,  Continued. 


III.  Vesicular 
Rales. 


CBEPITAST 
KALES. 


IV.  Cavernous 
Rales. 


GURGLING 
RALES. 


CHARACTER  OF   THE   SOUND. 


Fine,  dry,  crepitating  or 
crackling  sounds,  compared  to 
those  produced  by  fine  salt 
on  a  fire,  or  by  rubbing  a 
lock  of  hair  between  the 
thumb  and  finger  close  to 
the  ear.  They  resemble  the 
subcrepitant,  from  which 
they  must  be  distinguished. 
The  crepitations  ;uv  < 
size,  dry,  not  bubbling,  con- 
stant, not  variable,  ra/iidly 
evolved,  not  suspended  by 
coughing  and  expectoration, 
and  occur  only  with  inspira- 
tion. 


A  hollow,  gurgling  sound, 
bften  very  intense,  some- 
times metallic  or  amphoric, 
usually  of  low  pitch,  convey- 
ing the  impression  of  very 
large  bubbles  bursting  in  a 
large  space,  the  loudness.of 
the  gurgling  being  propor- 
tionate to  the  size  of  the  cav- 
ity. When  this  is  small, 
hardly  distinguishable  from 
coarse  bubbling  bronchial 
rales. 


RELATION    TO   INSPIRATION 
AND   EXPIRATION. 


With  inspiration  exclusively, 
and  near  the  end  of  it,  es- 
pecially in  forced  inspira- 
tion. 


With  either  or  both. 
Oftener    with    inspiration 
than  expiration. 


AUSCULTATION  AND  PERCUSSION. 
BALES,  Continued. 


35 


HOW    PRODUCED. 


.  Produced,  according  to 
the  most  rational  theory 
(Dr.  Carr's),  by  the  abrupt 
separation,  during  inspi- 
ration, of  the  walls  of  the 
'cles,  which  had, 
after  the  preceding  ex- 
piration, become  adherent 
by  means  of  the  viscid 
exudation  incident  to  the 
early  stage  of  inflamma- 
tion. 

This  mode  of  its  production 
can  be  illustrated  by  moisten- 
ing the  thumb  and  finger  with 
a  little  puste  or  solution  of 
gum  arabic,  and  alternately 
prus.-in<;  them  together  and 
separating  them  near  the  ear. 


Produced  by  the  burst- 
ing of  larirc  bubbles  arid 
the  agitation  of  a  mass  of 
liquid  in  a  cavity  of  con- 
siderable size.  When  the 
cavity  is  empty,  cavern- 
Otis  respiration  takes  the 
place  of  the  cavernous 
rules.  The  two  signs 
may  thus  confirm  each 
other.  Not  produced  if 
the  cavity,  is  full.  The 
communication  with  the 
bronchial  tubes  must  be 
unobstructed  and  below 
the  level  of  the  liquid. 
Therefore  gurgling  is  not 
heard  iu  every  case  of  a 
cavity. 


USUAL  SEAT. 


Most  commonly  over 
the  lower  part  of  the 
chest  behind,  on  one  side, 
oftener  the  right. 

Often  associated  with 
the  subcrepitant  rales  in 
the  resolution  of  pneu- 
monia. 


A  circumscribed  space, 
in  forty-nine  out  of  fifty 
cases  at  the  summit  of 
the  chest. 


DISEASES    INDICATED. 


Almost 
of  pneumonia. 

If  heard  only  over  a 
circumscribed  space  at 
the  summit  of  the  chest, 
phthisis  is  generally  indi- 
cated. Even  in  such 
cases  the  crepitant  rale  is 
indicative  of  a  circum- 
scribed pneumonic  proc- 
ess. 


Phthisis. 

Cavity  from  abscess,  cir- 
cumscribed gangrene,  can- 
cer, etc. 


36 


AUSCULTATION  AND  PERCUSSION. 


TABLE   NO.   6. 


CHARACTER   OF  THE   SOUND. 


RELATION  TO   INSPI- 
RATION   AND   EX- 
PIRATION. 


FRICTION 
SOUNDS. 


Grazing,  rubbing,  creaking  like  new 
leather,  grating,  crumpling,  rasping, 
the  harshness  varying  according  to 
the  roughness  of  the  surface  of  the 
pleura. 

The  grazing  and  rubbing  sounds, 
which  are  the  most  common,  may  be 
imitated  by  placing  over  the  ear  the 
palm  of  one  hand  and  moving  over 
its  dorsal  surface  slowly  the  pulpy  por- 
tion of  a  finger  of  the  other  hand. 

Intensity  very  variable,  sometimes 
heard  even  by  the  patient.  The 
sound  is  dry  and  appears  to  be  near 
the  ear,  not  continuous  generally,  but 
jerking,  rhythmical  with  respiration. 
Transient  or  lasting.  Occasionally 
attended  with  fremitus. 


With  both  or  with 
inspiration  alone. 

Very  rarely  with 
expiration  alone. 


METALLIC  TINK- 
LING. 


A  high-pitched,  abrupt,  short,  sil- 
very tone,  like  the  tinkling  of  a  small 
bell,  dropping  small  shot  into  a  brass 
basin,  etc.,  consisting  of  a  single 
sound,  or  more  commonly  of  two, 
three,  or  more  in  quick  succession. 
Accompanies  respiration,  speaking, 
and  coughing,  especially  the  two  lat- 
ter. Irregular  in  its  appearance. 
Only  liable  to  be  confounded  with  a 
somewhat  similar  sound  in  the  stom- 
ach. 


With  both  or 
either ;  especially- 
at  the  end  of  inspi- 
ration. 


AUSCULTATION  AND  PERCUSSION. 


37 


MORBID  PLEURAL  SOUNDS. 


HOW  PRODUCED. 


USUAL   SEAT. 


DISEASES    INDI- 
CATED. 


By  the  rubbing  together  of  two 
pleural  .surfaces  (pulmonary  with  cos- 
tal, aiid  ofteu  diaphragmatic  with  cos- 
tal) which  have  been  roughened  by 
lymph  or  other  deposit. 


In  common 
pleurisy  usually 
confined  to  a 
small  space  at  the 
middle  or  lower 
part  of  the  chest 
laterally  or  pos- 
teriorly ;  but  may 
be  more  or  less 
diffused,  and  occa- 
sionally is  heard 
over  the  entire 
chest. 

In  phthisis  at 
the  summit  of  the 
chest. 


Pleurisy. 

Also  in  phthisis 
and  pneumonia 
where  there  is  ac- 
companying s  e  c- 
ondary  .pleurisy. 


There  must  be  a  large  cavity,  contain- 
ing liquid  and  air  or  gas,  and  almost 
invariably  there  is  communication  with 
a  bronchial  tube. 

There  are  several  different  theories 
as  to  the  production  of  this  sound,  and 
probably  each  one  of  the  following 
(which  have  all  been  experimentally 
verified)  may  account  for  it  either  alone 
or  in  connection  with  the  others. 

1.  Drops  of  fluid  fall  from  the  upper 
part  of  the  space  upon  the  surface  of 
the   liquid   below,  when   the  patient, 
previously  1\  ing  down,  sits  or  stands 
up.     ( Laennec. ) 

2.  Air,  working  through  a  fistnlous 
orifice  opening  below  the  level  of  the 
liquid,  ri.-es  to  the  surface,  forming  bub- 
bles which    break    and    produce    the 
sound.     (Spittel.) 

3.  Simple  agitation  of  the  liquid  may 
give  rise  to  the  sound,  as  in  succussion, 
coughing,  etc. 

4.  Bubbles  of  mucus  bursting  at  the 
opening  of  a  fistulou.s  orifice  situated 
above  the  level  of  the  liquid. 


Generally  at  the 
middle  third  of 
the  chest,  in  front, 
behind,  or  at  the 
side. 

Sometimes  dif- 
fused over  the 
entire  chest  on 
one  side. 

Sometimes  a 
circum  scribed 
space  at  the  sum- 
mit. 


Almost  pathog- 
nomonic  of  pneu- 
mo-hydrothorax. 

Very  rarely  in. 
phthisical  cavities. 


38 


AUSCULTATION  AND  PERCUSSION. 


TABLE  NO.  6,  Continued. 


VARIETIES. 

I 


CHARACTER  OF   THE   SOUND. 


RELATION  TO  INSPI- 
RATION  AND   EX- 
PIKAT1ON. 


SPLASHING. 

(Hippocratic  succus- 
SIOQ  sound.) 


Such  a  noise  as  is  produced  by 
shaking  a  bottle  partly  filled  with 
liquid. 

Only  liable  to  be  confounded  with  a 
somewhat  similar  sound  in  the  stom- 
ach. 

Often  it  has  a  high-pitched  am- 
phoric tone,  and  may  be  mingled  with 
metallic  tinkling.  Sometimes  loud 
enough  to  be  heard  at  a  distance. 


AUSCULTATION  AND  PERCUSSION. 


39 


MORBID  PLEURAL  SOUNDS,  Continued. 


HOW  PRODUCED. 

USUAL  SEAT. 

DISEASES  IN- 

DICATED. 

Produced  by  jerking  the  body  of  the 
patient  with  an  abrupt  forcible  move- 

Generally over 
the  whole  of  the 

Pathognomonic 
of   pneumo-hydro- 

ment,  the  ear  being  in  contact  with  or 

affected  side,  un- 

thorax. 

in  close  proximity  to  the  chest. 

less  there  are  ad- 

Sometimes produced  unintentionally 
by  the  patient  himself,  by  quick  mo- 
tions,   such    as    horseback    exercise, 

hesions. 
Very  rarely  at  the 

Very  rarely  in   tu- 
bercular   and     other 
cavities  in  the  lung. 

•        .         , 

summit  of  the  chest. 

jumping,  etc. 

The  liquid  must  not  be  too  abun- 

dant nor  too  thick,  and  there  must 

also  be  air  in  the  cavity. 

40  AUSCULTATION  AND  PERCUSSION. 

TABLE  NO.  7. 


VARIETIES. 


CHARACTER  OF    THE     SOUND. 


TBACHEAL  VOICE. 

(Tracheophony,  laryn- 

geal  voice,  laryngoph- 

ony.) 


A  strong  resonance,  with  a  powerful  sensation  of  con- 
cussion or  shock,  and  also  with  a  strong  sense  of  vibration 
or  thrill  called  fremitus,  which  can  be  appreciated  bv  the 
ear  as  well  as  by  palpation.  The  voice  is  concentrated  and 
near  the  ear,  seeming  to  pass  right  through  the  stethoscope. 
Sometimes  the  articulated  words  are  transmitted  so  as  to 
be  heard  as  distinctly  as  when  coming  direct  from  the 
lips.  When  this  occurs  over  the  chest  as  a  result  of  dis- 
ease, it  is  called  perfect  pectoriloquy.  Oftener,  however, 
the  transmission  of  speech  from  the  trachea  furnishes  a 
type  of  imperfect  pectoriloquy.  All  these  phenomena 
may  differ  in  intensity.  The  variations  in  the  first  three, 
however,  —  resonance,  shock,  and  fremitus,  —  do  not  al- 
ways correspond  with  the  variations  in  the  distinctness 
with  which  speech  is  transmitted. 


TRACHEAL 
WHISPER. 

(Whispering 
tracheophony.) 


There  is  little  or  no  shock  or  fremitus-.  Whispered 
words  are  transmitted  more  or  less  perfectly,  more  so 
generally  than  loud  words  ;  this  feature  corresponding  to 
the  morbid  sign  called  whispering  pectoriloquy. 


NORMAL  THORACIC 
VOCAL 

RESONANCE. 


The  resonance  is  much  weaker  than  in  tracheophony, 
and  is  quite  variable  in  intensity.  Often  over  portions  of 
the  chest  none  is  appreciable,  and  in  some  persons  it  is 
absent  over  the  entire  chest.  The  sound  is  diflust-d  and 
seems  farther  removed  from  the  ear,  rarely  accompanied 
with  shock,  and  not  always  with  fremitus.  The  sound 
often  amounts  to  little  more  than  a  humming  or  buzzing. 
No  pectoriloquy. 


NORMAL 

BRONCHIAL 

WHISPER. 


The  characters  of  the  sounds  produced  by  the  whis- 
pered voice  are  identical  with  those  produced  by  the  act  of 
expiration,  in  all  respects  except  that  the  souncn  are  more 

intense,  generally,  than  those  even  of  a  forced 'expira- 
'ion.  Tlif  h,i"ii~irv  is  varhhle,  as  in  the  preceding. 
There  i>  tue  same  difference  between  thi<  and  the  tracheal 
whisi-er  \virh  regard  to  diffusion,  concentration,  and  near- 
ness to  the  ear  that  there  i<  between  the  normal  thoracic 
vocal  resoii-mc'1  and  the  tracheal  voice. 


AUSCULTATION  AND  PERCUSSION. 
THE  VOICE  IN  HEALTH. 


41 


HOW  PRODUCED. 


USUAL  SEAT. 


The  resonance  by  the  reverberation 
of  the  voice  in  the  sound-reflecting 
tube,  the  shock  by  the  sudden  arrest 
of  the  column  of  expired  air  by  the 
act  of  speaking,  the  fremitns  by  the 
vibrations  of  the  tracheal  tube  in  con- 
nection with  those  of  the  vocal  chords, 
and  the  distinct  transmission  of  speech 
by  the  concentrating  and  sound-reflect- 
ing properties  of  the  hollow  tube. 


Trachea  and  larynx. 

Apply  the  stethoscope  over  the  broad  sur- 
face of  the  thyroid  cartilage  or  just  above 
the  sternal  notch.  To  bring  out  the  vocal 
phenomena  to  the  best  advantage,  both  here 
and  over  the  chest  in  health  and  in  disease, 
the'  patient  should  be  instructed  to  count 
slowly  one,  two,  three,  one,  two,  three,  etc., 
at  first  with  the  loud  voice  and  afterwards  in 
a  whisper. 


The  sound  corresponds  to  the  sound 
of  expiration  in  tracheal  or  laryngeal 
respiration,  and  is  in  fact  identical 
•with  it. 


Trachea  and  larynx. 


The  vibrations  are  weakened  and 
diffused  by  passing  through  the  sub- 
divisions of  the  bronchi  and  the 
spongy  tissue  of  the  lung  before  reach- 
ing the  surface  of  the  chest. 


There  are  considerable  variations 
in  this  sound  in  the  different  regions 
of  the  chest,  it  being  more  intense  in 
the  infra-clavicular  and  inter- scapular 
regions  than  in  the  axillary  and  infra- 
axillary  ;  and  in  the  latter  more  than 
in  the  mammary  and  infra-mammary. 
There  is  the  least  resonance  in  the 
scapular  region. 

There  is  also  often  a  slight  difference  in 
the  two  sides  comparatively  When  there  is 
any  difference,  the  right  side  is  the  more 
resonant.  This  1'ist  rcmnrk  applies  also  to 
fremitus.  The  amount  of  the  fremitus,  how- 
ever, is  not  necessarily  proportionate  to  that 
of  the  resonance. 


The  conduction  of  sound  by  the 
whispered  voice  is  chiefly  by  the  air 
contained  in  the  bronchial  tubes. 


About  the  same  variations  are  ob- 
served as  in  the  preceding. 


42 


AUSCULTATION  AND  PERCUSSION. 


TABLE  NO.  8. 


VARIETIES. 


CHARACTER  OF   THE   SOUND. 


DIMINISHED  AND  SUP- 
PRESSED VOCAL 
RESONANCE  AND  FBE- 

M1TDS. 


Simply  less  in  intensity  than  normal,  or  absent 
altogether.  There  being  no  standard  of  inten>ity, 
comparison  must  be  made  between  the  two  sides, 
allowing,  of  course,  for  the  slight  possible  differ- 
ence in  health.  (Table  No.  7.) 

The  fremitus  generally,  but  not  always,  lessened 
in  the  same  proportion  as  the  resonance. 


INCREASED  VOCAL 

RESONANCE  AND 

FREMITUS. 


Merely  an  increase  in  intensity,  without  change 
in  other  respects.  Generally  associated  with  the 
broncho-vesicular  respiration. 


INCREASED  BRONCHIAL 
WHISPER. 


Same  as  the  expiratory  sound  in  broncho-vesic- 
ular respiration,  namely,  increase  of  intensity  and 
length,  more  or  less  tubular  in  quality,  and  higher 
iu  pitch  than  the  whisper  in  health,  these  altera- 
tions being  proportionate  to  the  degree  of  solid- 
ification. 


Vocal  sound  concentrated  and  near  the  ear. 
Pitch  higher  than  normal.  Intensity  and  fremi- 
tns  variable ;  may  be  greater  or  less  than  in 
health. 


BRONCHOPHONY. 


WHISPERING  BRON- 
CHOPHONY. 


Sanv  ;IN  the  expinitorv  sound  in  the  bronchial 
respiration,  namely,  intensified,  long,  high  pitched, 
and  tnliiiiar. 


AUSCULTATION  AND  PERCUSSION. 
THE  VOICE  IN  DISEASE. 


HOW   PRODUCED. 

USUAL  SEAT. 

DISEASES    INDICATED. 

By  th%  removal  of  the 
lungs    from    the    thoracic 
walls,  or  by  anything  that 
prevents  the  circulation  of 
the  column  of   air  in   the 
tubes  which  propagate  the 
sound. 

When     the     pleural 
cavity  is  partially  filled 
with    fluid,   the    vocal 
resonance  and  f  remitus 
are  diminished  or  sup- 
pressed below  the  level 
of   the    liquid,    but   in- 
.creased  generally   just 
above  the  level,  owing 
to  the  condensation. 

Pleuritic  effusion,  em- 
pyema,       hydrothorax, 
pneumo  -  hydrothorax, 
obstruction     of      bron- 
chial tubes  by  mucus  or 
by  the  pressure  ofaneu- 
rismal  or  other  tumors. 

Exceptional  in  solidifica- 
tion, but  sometimes  observed 
in  complete  solidification  of 
pneumonia,  abscess  full  of 
pus,  cavity  filled  with  liquid, 
pulmonary  cedcina. 

By  slight  consolidation  of 
the  lung  tissue  around  the 
air    tubes,     whereby     the 
sound-reflecting    power  of 
the  tubes  is  increased,  and 
the  pulmonary  parenchyma 
is  rendered  more  homoge- 
neous and  a  better  sound- 
conductor. 

Not  confined  to  any 
part  of  the  chest,  but 
usually  most  marked 
and  of  the  greatest  sig- 
nificance towards  the 
apices  of  the  lungs  in 
phthisis. 

Phthisis. 
Pneumonia. 
Compressed  lung   in 
moderate    pleuritic    ef- 
fusion  and  collapse  of 
pulmonary  lobules. 

Carcinoma,    haemorrhagie 
infarctus.     Sometimes  over 
cavities. 

Same  as  the  preceding. 

Same  as  the  preceding. 

Same  as  the  preceding. 

Same  as  the  preceding, 
except  that   the  solidifica- 
tion   is  greater,  and  some- 
times complete.     Less  solid- 
ification  is   required   than 
for  the  production  of  bron- 
chial  respiration.      There- 
fore bronchophony  may  be 
associated  with  a  broncho- 
vesicular      respiration      as 
well  as  with  bronchial. 

In    pneumonia   gen- 
erally the  middle   and 
lower  thirds  behind. 
Of  great  importance 
aa&nggesthre  of  phthisis 
when   existing    at    the 
apex  of  the  lung. 
In  pleuritic  effusion, 
over  condensed  lung  at 
summit  of  chest. 

Pneumonia. 

Phthisis. 

Lung  condensed  by  effu- 
sion in  pleurisy  or  pneumo- 
hydrothorax,  or  by  pressure 
of    a     tumor,    collapse    of 
pulmonary  lobules,  cancer, 
or  bronchial  dilatation,  the 
tubes  being  surrounded   by 
condensed     and     indurated 
lung. 

Same  as  the  preceding. 

Same  as  the  preced- 
ing. 

Same  as  the  preced- 
ing. 

44  AUSCULTATION  AND  PERCUSSION. 

TABLE  NO.  8,  Continued. 


VARIETIES. 


CHARACTER  OF  THE   SOUND. 


CAVERNOUS  WHISPER. 


Same  as  the  expiratory  sound  in  the  cavernous 
respiration,  namely  :  low  pitch  and  blowing  (non- 
tubular)  quality,  with  variable  intensity. 


AMPHORIC  VOICE  AND 
WHISPER. 


A  ringing  sound  of  a  metallic  quality,  not  dis- 
tinctly articulated,  not  transmitted  forcibly 
through  the  stethoscope,  but  resembling  the 
sound  produced  by  speaking  into  an  empty  jar. 
The  amphoric  quality  may  accompany  the  loud 
voice  or  whisper,  more  especially  the  latter,  the 
resonance  and  fremitus  of  the  loud  voice  obscuring 
somewhat  the  musical  intonation. 


PECTORILOQUY  AND 

WHISPERING  PECTO- 

KILOQUY. 


Articulated  words  are  transmitted  directly  through 
the  stethoscope  into  the  ear.  This  is  more  fre- 
quent with  the  whispered  than  with  the  loud 
voice.  Care  must  be  taken  not  to  confuse  the 
words  coming  directly  from  the  patient's  mouth 
with  the  transmission  of  them  through  the  chest. 
Unless  a  double  stethoscope  is  used,  one  ear  must 
be  closed.  This  is  a  rare  sign,  but  the  type  of  it 
can  be  studied  in  health  in  connection  with 
tracheal  voice. 


A  tremulous,  bleating  or  quavering  sound,  like 
the  cry  of  a  goaf,  from  which  the  term  is  derived, 
and  often  compared  to  the  "Punch  and  Judy" 
voice.  Synchronous  with,  but  of  a  higher  pitch 
than,  the  voice  of  the  patient,  or  else  follow- 
ing it  like  a  feebly  whispered  echo,  and  rarely 
traversing  the  stethoscope. 


METALLIC  TINKLIXG. 


Has  the  same  characters  when  heard  in  connec- 
tion with  the  loud  or  whispered  voice  as  with  res- 
piration (which  see),  but  is  more  intense. 


AUSCULTATION  Ai\'D  PERCUSSION. 
THE  VOICE  IN  DISEASE,  Continued. 


HOW    PRODUCED. 

USUAL   SEAT. 

DISEASES  INDICATED. 

Produced     by     the    air 

A  circumscribed  space, 

Phthisis. 

passing  out  of  an  empty, 

generally  at  summit  of 

superficial  cavity  vfithjiac- 
cid  walls. 

chest,  — 

Purulent,  gangrenous,  or 
cancerous  excavation. 

Or  in  other  parts. 

By  the  reverberation  of 

Same    as    amphoric 

Same    as    amphoric 

the  voice,  causing  an  echo, 

respiration. 

respiration. 

in  a  lar«e  cavity  with  rigid 

walls,  and   subject  to  the 

same  conditions  as  in  the 

production     of     amphoric 

respiration  (which  see). 

"  Sometimes  by  the  con- 

" Not  confined  to  any 

Chiefly  Phthisis. 

densation    of    lung    tissue 

portion  of    the  lungs, 

around   a  large  bronchus, 
whereby   the   transmission 
of  the  sound  to  the  ear  is 

but     occurring      most 
commonly  at  the  apices 
and  in  the  upper  lobes." 

Sometimes    pneu  m  o  n  i  a, 
pouchlike  dilatation  of  bron- 
chi, circumscribed  gangrene, 
and  abscess. 

facilitated.      More    gener- 

ally  by  the  formation   of 

cavities  possessing  smooth, 

sound-reflecting  walls." 

• 

By  the  vibrations  conse- 

Not confined  to  any 

Pleuritic  effusion. 

quent  on  the  existence  of  a 

portion  of    the  chest, 

thin   stratum  of  liquid  in 

but  most  common  at  or 

Pleuro-pneumonia. 

the  pleural  cavity. 
Not  apt  to  occur  when 

near  the  inferior  angle 
of  the   scapula  ;    from 

Hydrothorax. 
Empyema. 

the  chest  is  more  than  half 

here    often    extending 

full   of  liquid.     The   lung 

to     the    inter-scapular 

must  be  more  or  less  con- 

space,  and,  in  a  zone 

densed  at  the  level  of  the 

from  one  to  three  fin- 

liquid.    This  accounts  for 

gers    broiid,    following 

the     elevation     of     pitch. 

the  line  of  the  ribs  to- 

When  there   becomes  too 

wards  the  nipple   (the 

much  liquid,  the  aegophony 

patient  sitting).     This 

stops.     Therefore  in  acute 

line   indicates   not  the 

pleurisy  it  rarely  continues 

level  of  the  liquid,  but 

longer  than  two   or  three 

the  points  where  it  has 

days,  sometimes  only  for  a 

the  requisite  degree  of 

few  hours. 

thinness      to     produce 

aegophony. 

As  in  Table  No.  6. 

As  in  Table  No.  6. 

Mostly     Pneumo-hy- 

drothorax. 

46  AUSCULTATION  AND  PERCUSSION. 

TABLE  NO.  9. 


VARIETIES. 


CHARACTER  OF  THE  SOUND. 


HOW  PRODUCED. 


NOBMAL  VESIC- 
ULAR 
RESONANCE. 

(Pulmonary.) 


A  full,  clear,  prolonged 
sound,  of  low  pitch,  its  qual- 
ity xw  r/eiieris,  only  to  be  ap- 
preciated by  actually  hearing 
it,  and  its  intensity  varying 
with  the  force  of  the  blow, 
the  elasticity  of  the  chest 
walls,  the  thickness  of  the 
layer  of  muscles  and  fat  cov- 
ering them,  and  the  degree 
of  inflation  of  the  lungs. 


By  the  vibration  of  the 
air  in  the  uniform,  elastic, 
spongy  tissue  of  the  lung 
when  percussed. 


FLATNESS. 

(Absence  of  reso- 
nance.) 


The  sound  is  completely 
deadened,  and  resembles  that 
produced  by  percussing  the 
thigh  or  shoulder.  The 
finger  used  as  a"  pleximeter 
experiences  a  greater  sense 
of  resistance  than  normal, 
especially  in  early  life,  before 
the  costal  cartilages  have 
ceased  to  be  elastic. 


The  absence  of  resonance 
is  occasioned  by  scrum  or 
pus  in  the  pleural  sac,  serum 
in  the  air-vesicles,  complete 
solidification  of  lung  tissue, 
tumors,  etc. 


DULLNESS. 

(Diminished  reso- 
nance.) 


Intermediate  between  the 
two  preceding,  the  vesicular 
resonance  being  not  lost  but 
only  partially  deadened.  The 
degree  of  dullness  varies  in- 
definitely. The  pitch  is 
higher  than  normal.  The 
sense  of  resistance  is  in- 
creased in  proportion  to  the 
degree  of  dullness. 


By  the  same  causes  as  the 
preceding,  though  existing 
to  a  lesser  extent.  The  rela- 
tive proportion  of  solids  or 
liquids  to  air  in  the  lungs  is 
morbidly  increased. 


AUSCULTATION  AND  PERCUSSION. 
PERCUSSION  SIGNS. 


47 


WHERE   OBSERVED   IN  HEALTH. 


DISEASES  INDICATED. 


Most  strongly  marked  in  the  infra- 
clavicular  regions.  In  the  scapular 
and  interscapular  regions,  on  account 
of  the  Livers  of  bone  and  muscles,  the 
resonance  is  diminished,  as  it  is  also 
where  the  lung  overlaps  the  heart  and 
liver.  In  different  regions  the  reso- 
nance varies  so  much  that  what  would 
be  normal  for  one  would  be  decidedly 
abnormal  for  another.  Each  must  be 
carefully  studied  by  itself.  The  area  of 
healthy  resonance  is  of  course  greater 
with  a  full  inflation  of  the  lungs  than 
in  tranquil  breathing,  and  less  with  a 
forced  expiration. 

In  some  persons  the  resonance  is  slightly 
diminished  on  the  right  side  in  the  inlra- 
clavicuiar  region  in  health,  but  never  on  the 
left  side. 


Over  the  liver  below  the  line  of  he- 
patic flatness. 

The  lower  border  of  the  right  lung  marks 
the  line  of  hepatic  flatness,  and  the  upper 
border  of  the  underlying  liver  the  line  of 
hepatic  dullness. 


Pneumonia. 
Pleuritic  effusion. 
Empyema. 
Hydrothorax. 

Phthisis,  pulmonary  oedema,  condensation 
of  lung  from  compression  or  from  pulmonary 
collapse,  cancer,  aneurism,  etc. 


Over  the  heart  and  spleen ;  in  the 
places  where  the  lungs  overlap  the 
liver  or  heart  ;  over  the  mammarv 
gland  in  females ;  over  thick  layers  of 
iiiu>cl(;s  on  the  ribs,  especially  behind; 
and  all  over  the  chest  in  very  fat  per- 
sons. 

In  some  persons  there  is  in  health  a  slight 
degree  of  dullness  at  the  summit  of  the  chest 
on  the  right  side. 


The  same  diseases  as  the  above, 
where  the  same  physical  conditions 
exist  to  a  less  extent.  In  many  of 
them  dullness  is  more  common  than 
flatness.  The  deposit  of  phthisis  is 
very  rarely  sufficient  to  give  rise  to 
more  than  dullness,  and  miliary  tuber- 
cles, unless  in  great  quantities,  may 
not  even  give  rise  to  dullness.  Con- 
gestion of  the  lung  may  give  rise  to 
dullness,  but  never  to  flatness. 

Rarely  we  find  dullness  in  emphysema, 
owing  probably  to  increased  tension  of  lungs 
and  walls  of  chest.  There  may  be  slight  dull- 
ness from  exudation  of  lymph  on  pleura. 


48  AUSCULTATION  AND  PERCUSSION. 

TABLE   NO.  9,  Continued. 


VARIETIES. 


CHARACTER  OF  THE   SOUND. 


HOW   PRODUCED. 


A  drum-like  sound,  as  its 
name  signifies ;  the  term 
often  used  to  denote  any  res- 
onance which  is  not  vesic- 
ular. It  is  of  variable  in- 
tensity, either  greater  or  less 
than  the  vesicular,  of  higher 
pitch,  and  accompanied  with 
a  sense  of  less  resistance  to 
the  finger. 


TTMPANITIC 

RESONANCE. 


It  requires  for  its  produc- 
tion a  large  space  filled  with 
air,  and  bounded  by  moder- 
ately tense,  elastic  walls,  capa- 
ble of  reflecting.sonorous  vi- 
brations. If,  however,  the 
tension  is  extreme,  the  con- 
tained air  does  not  vibrate, 
the  tympanitic  quality  is 
lessened  or  destroyed,  and 
the  sound  may  become  quite 
dull.  When  a  common  drum 
is  made  extremely  tight  and 
there  is  no  escape  for  the  air, 
the  same  dull  effect  is  pro- 
duced on  being  struck. 

Tympanitic  resonance  oc- 
curs under  the  following  con- 
'ditions  :  — 

1.  From  air  or  gas  in  the 
pleural   cavity.      (Here   the 
resonance    is    more    intense 
than  the  normal  vesicular.) 

2.  From  air  in  pulmonary 
cavities. 

3.  Singularly  enough,  and 
contrary  to  what   might  be 
expected,    tympanitic     reso- 
nance  is    often   heard   over 
partially  solidified  lung  (giv- 
ing place  to  dullness  when 
the     solidification     becomes 
complete). 

Where  the  upper  lobe  is  thus 
resonant,  as  in  phthisis  before 
cavities  have  formed,  and  in  pneu- 
monia, it  is  generally  explained 
by  saying  that  the  resonance  must 
come  from  the  air  in  the  lower 
part  of  the  trachea  and  the  pri- 
mary bronchi,  being  better  con- 
ducted by  solidified  than  by 
healthy  lung  ;  and  where  the 
lower  lobe  is  solidified,  that  the 
tympanitic  resonance,  if  present, 
is  conducted  in  a  similar  way  from 
the  stomach  or  colon.  Fuller, 
however,  thinks  it  comes  from  the 
presence  of  air  pent  up  in  lung 
tissue  in  the  immediate  vicinity  of 
consolidated  tissue.  Skoda  and 
others  explain  it  by  diminution  of 
tension. 


AUSCULTATION  AND  PERCUSSION. 
PERCUSSION  SIGNS,  Continued. 


WHERE  OBSERVED   IN  HEALTH. 


DISEASES   INDICATED. 


Heard  over  the  stomach  and  bowels. 


Pneumothorax. 

Pn  eu  mo-hy  drothorax. 

Phthisis. 

Cavities  after  abscess,  etc. 
Dilatation  of  bronchi. 
Pneumonia. 


50  AUSCULTATION  AND  PERCUSSION. 

TABLE  NO.  9,  Continued. 


VARIETIES. 


CHARACTER   OF  THE   SOUND. 


HOW   PRODUCED. 


EXAGGERATED 
RESONANCE. 

(Vesiculo-tym- 
panitic.) 


Intermediate  between  the 
normal  vesicular  and  the 
tympanitic  resonance,  and 
partaking  of  the  characters 
of  each.  The  pitch  high  in 
proportion  as  the  tympanitic 
quality  predominates.  In- 
tensity greater  than  normal. 


1.  By  abnormal  dilatation 
of  the  air  cells. 

2.  If  the  effusion  in  pleu- 
risy  rises  much   above    the 
middle  of  the  chest,  the  pres- 
sure condenses  the  luug  above 
the  liquid,  and  dullness  en- 
sues.    Wit£  a  less  amount 
of  liquid,  however,  the  reso- 
nance is  generally  exaggera- 
ted.   Also,  where  pneumonia 
solidifies  one  lobe,  the  reso- 
nance over  the  other  is  gen- 
erally  exaggerated.      Prob- 
ably both  cases  are  explained 
by  assuming  a  condition  ap- 
proximating to  emphysema 
in  the  lobe  above  the  liquid 
in     pleurisy,    and     in     the 
healthy  lobe  in  pneumonia, 
they  expanding  prop.ortion- 
ally  to  the  expansion  caused 
by  the  diseased  condition  in 
the  affected  part. 


AMPHORIC 

RESONANCE. 


A  kind  of  musical  intona- 
tion, like  the  sound  obtained 
by  percussing  an  empty  jar 
(amphora).  It  may  be  imi- 
Jated  by  closing  the  mouth, 
inflating  the  cheeks,  but  not 
too  tensely,  and  then  filliping 
them  with  the  finger. 


The  cavity  must  contain 
air,  must  have  somewhat 
rigid  walls,  must  be  super- 
ficial or  else  covered  by  so- 
lidified lung,  and  there  must 
be  free  communication  with 
the  bronchial  tubes.  The 
sound  can  be  heard  better 
if  the  ear  or  stethoscope  is 
brought  close  to  the  patient's 
open  mouth.  Use  slow  and 
heavy  percussion. 


CRACKED-METAL 
RESONANCE. 

(Bruit  du  pot  fete.) 


Like  the  sound  produced 
by  striking  a  cracked  earth- 
enware or  metal  jar  or  other 
vessel  Can  be  imitated  by 
the  school-boy  trick  of  fold- 
ing the  hands  so  as  to  form 
a  hollow,  and  striking  the 
back  of  one  of  them  on  the 
knee.  A  loud,  short,  hollow, 
metallic  sound,  accompanied 
with  hissing. 


Produced  exactly  as  in  the 
school-boy  trick  referred  to, 
by  the  sudden  expulsion  of 
air,  and  its  forcible  contact 
with  the  sides  of  the  passage 
through  which  it  is  driven. 
The  same  conditions  are  nec- 
essary to  its  production  as  in 
amphoric  resonance. 


AUSCULTATION  AND  PERCUSSION. 
PERCUSSION   SIGNS,  Continued. 


51 


WHERE  OBSERVED   IN  HEALTH. 


DISEASES   INDICATED. 


Emphysema  (vesicular  or  interlob- 
ular  or  secondary  to  phthisical  de- 
posit, etc.). 

Pleurisy  with  effusion. 

Pneumonia. 


Occasionally  produced  in  children 
over  a  primary  bronchus,  owing  to  the 
yielding  of  the  costal  cartilages. 


Mostly    phthisical    cavities,    some- 
times pneumo-hydrothorax. 

Occasionally  at  the  summit  of  the  chest  in 
pleurisy  with  effusion. 


As  in  the  preceding1. 

It  may  be  produced  unintentionally 
by  the  imperfect  application  of  the 
finger  or  pleximeter  to  the  chest  walls, 
and  the  expulsion  of  air  from  beneath 
it. 


Mostly  phthisical  cavities. 

Occasionally  in  solidification  of  the  tipper 
lobe  from  inflammation  or  condensation, 
where  the  air  is  suddenly  and  forcibly  ex- 
pelled through  the  bronchus,  especially  if 
percussed  near  the  sternum. 


PART  II. 

THE  PHYSICAL  DIAGNOSIS  OF  DISEASES 
OF  THE  LUNGS  AND  HEART. 


54 


THE  PHYSICAL  DIAGNOSIS 
TABLE  NO.   10. 


INSPECTION    AND 

DISEASE. 

PERCUSSION. 

RESPIRATION. 

MENSURATION. 

ACUTB 

Diminution      in 

Sometimes  slight 

Feeble. 

PLECKISY. 

respiratory    move- 

dullness. 

Jerking. 

ments  on   account 

First  Stage. 

of  pain.  Body  bent 

towards      affected 

(Exudation  of 

side  for  the  same 

lymph.) 

reason. 

Little  or  no  mo- 
tion of  the   chest 

A  sense   of    re- 
sistance,  and  fiat- 

Feeble,   broncho- 
vesicular    or   bron- 

walls on  the  affect- 

ness or  dullness  at 

chial       respiration 

ed    side,     but    in- 

the   base    of    the 

over  the  compressed 

creased  motion  on 

chest,  terminating 

lung,     with     occa- 

the healthy  side. 

abruptly  above   in 

sionally    a    feeble, 

Enlargement  of 

a  curved  line  which 

distant,      bronchial 

side    in  all   direc- 

is not   altered   by 

respiration  all  over 

tions  by  measure- 

respiration,       but 

the  chest. 

ment,  and  oblitera- 

which may  be  made 

Respiration  gen- 

Second Stage. 

tion  of  intercostal 

to  shift  by  chang- 

erally     suppressed 

(Effusion  of 

serum.) 

spaces,     especially 
at    lower  part    of 
chest. 

ing    the     patient's 
posture,     unless 
there  are  adhesions 

below    the  level  of 
the   liquid,   but  in- 
creased    on     unaf- 

of the  pleural  sur- 

fected  side  during 

faces,  or  the  chest 

all     three     stages, 

is  full  of  liquid. 

especially    in    thia 

Generally  exag- 

stage. 

gerated   resonance 

above  the  level  of 

the      liquid,     and 

rarely  the  amphoric 

or     the     cracked- 

metal  resonance  at 

the  summit. 

Mobility  of  chest 

The  line  of  flat- 

Respiration grad- 

walls partially  re- 

ness   is  gradually 

ually  returns  to  its 

turning,  intercostal 

lowered,  but  dull- 

normal     condition 

spaces      becoming 

ness  often  remains 

from    the     summit 

normal,    and    en- 

for   an     indefinite 

downwards,  though 

largement     disap- 

time at  the  base  of 

fee  Me      often      for 

Third  Stage. 

pearing. 

the    chest,    where 

weeks  and  months. 

(Absorption  and 

After     recovery 
there     occurs,    in 

the  compression  of 
the   lung  and   the 

A  bstuce  of  respi- 
ration at  the  base 

resolution.) 

some      cases 

accumulation       of 

frequently  remains 

(though  seldom  in 

solid  plastic  mate- 

for a  long  time. 

comparison      with 

rial   is  often  very 

chronic    pleurisy), 

great. 

contraction  of  the 

whole  side. 

OF  DISEASES  OF  THE  LUNGS. 
TABLE  NO.   10. 


55 


RALES. 

VOCAL 

PALPATION. 

REMARKS. 

RESONANCE. 

Rubbing  friction 

Deep-seated     ten- 

When not  spe- 

sounds often 

derness. 

cified,   the   signs 

heard,  which  are 

mentioned  in  this 

almost  pathogno- 

table      are     ob- 

monic   when    at 

served  over  the 

the  middle  or  infe- 

affected   portion 

rior  part  of  chest, 

of  the  lung  only. 

or  all  over  the  side. 

A    friction 

Lessened      or 

Fluctuation  some- 

Generally   the 

sound    is    rarely 
heard  even  in  this 

suppressed  below 
the  level  of  the 

times  apparent.    Vo- 
cal fremitns  lessened 

pleural  cavity  is 
not    more     than 

stage,  where  the 

liquid,    but     in- 

or suppressed  below 

half  or  two  thirds 

lung  is  attached 

creased  above. 

the  level  of  the  liquid, 

full     in      acute 

by  bands  of  false 

Sometimes  bron- 

but  increased  above. 

pleurisy. 

membrane  to  the 

chophony  above 

If  the  heart  is  dis- 

thoracic     walls, 

the  level,  or  pec- 

placed,    it    may    be 

and  also  over  the 

toriloquy    (espe- 

heard and  often  felt 

compressed  lung 

cially   in  pleuro- 

pulsating  even  to  the 

higher  up. 

pneumonia,      or 

right  of  the  sternum, 

pleurisy    with 

or  farther  to  the  left 

phthisis),   heard 

than  normal   in  the 

best     over    the 

direction  of   the  ax- 

scapular and  in- 

illa  ;    the     displace- 

terscapular    re- 

ment   being    to   the 

gions  on  account 

right  if  the  effusion 

of  the  usual  sit- 

is on  the  left  side,  and 

uation    of     the 

to  the  left  if  the  effu- 

compressed lung. 

sion  is  on  the  right 

Sometimes 

side. 

* 

aegophony    near 

the   level  of  the 

liquid. 

A  rasping,  grat- 

Gradually ap- 

Sometimes a  fric- 

ing, creaking, 

proaches  to  the 

tion    fremitus.     The 

rough,  fr  ictio  n 

normal.      Some- 

he-art,   if   previously 

murmur     is    now 

times  aegophony. 

displaced,   gradually 

very     often     ob- 

returns to  the    prae- 

served,  especially 

cordia,    unless    held 

with   a   deep   in- 

by morbid  adhesions  ; 

spiration,     some- 

and curiously  enough, 

times  loud  enough 

the      suction     force 

to  be  heard  at  a 

caused  by  absorption 

distance,  and  va- 

may now  even  draw 

rying  in  duration 

it  too  far  in  the  oth- 

from a  very  short 

er  direction,  —  if  the 

time    to    several 

effusion     has      been 

months,     ceasing 

right-sided,    towards 

with  adhesion. 

the    right  ;     if    left- 

sided,  further  to  the 

left  than  normal. 

56 


THE  PHYSICAL  DIAGNOSIS 
TABLE  NO.  10,  Continued. 


INSPECTION  AND 
MENSUKATION. 


PERCUSSION. 


RESPIRATION. 


CHRONIC 
PLEURISY. 

(If  the  chest  is 
full  of  fluid.) 


Perfect  or  almost 
perfect  immobility 
of  side  of  chest 
(with  increase  of 
motion  on  healthy 
side).  Generally  di- 
latation of  side, 
and  as  a  rule,  even 
if  this  be  not  so, 
the  intercostal  de- 
pressions are  ef- 
faced or  lessened. 
This  is  particularly 
noticeable  at  the 
end  of  inspiration. 
The  maximum  en- 
largement of  the 
side  is  about  two 
inches. 

Permanent  con- 
traction after  re- 
covery. 


Flatness  ev  ery- 
where  on  affected 
side,  even  extend- 
ing over  the  ster- 
num some  distance 
on  the  other  side. 


Wanting ;  except 
at  the  summit  over 
or  near  the  com- 
pressed lung,  where 
it  is  bronchial.  Ex- 
ceptionally, how- 
ever, the  bronchial 
respiration  extends 
over  the  whole  side 
or  the  greater  part 
of  it. 

Respiratory  mur- 
mur exaggerated  on 
healthy  side. 


EMPYEMA. 


The  amount  of 
pus  is  generally 
even  greater  than 
that  of  the  serum 
in  chronic  pleurisy, 
causing  still  greater 
dilatation  of  the 
chest.  The  obliter- 
ation of  intercostal 
depressions  is  oft- 
ener  noticed  than 
in  pleurisy. 


Same  as  chronic 
pleurisy. 


Same  as  chronic 
pleurisy. 


OF  DISEASES  OF  THE  LUNGS. 
TABLE  NO.  10,  Continued. 


57 


RALES. 


VOCAL 

RESONANCE. 


PALPATION. 


As     in     acute 
pleurisy. 


Lessened  o  r 
suppressed  ex- 
cept at  the  sum- 
mit  behind, 
where  there  may 
be  loud  and  whis- 
pering  bron- 
chophony  and  in- 
creased vocal  res- 
onance. jEgoph- 
ony  is  rare. 


Fluctuation  some- 
times apparent.  Vo- 
cal fremitus  lessened 
or  suppressed. 

Heart  displaced 
even  more  than  is 
usual  in  acute  pleu- 
risy. Mediastinum 
displaced  laterally. 
Liver  and  stomach 
often  displaced  down- 
wards, sometimes  as- 
cending even  higher 
than  before  with  the 
contraction  accom- 
panying recovery. 


If  the  chest  is 
only  partially 
filled,  the  signs 
are  the  same  as 
in  acute  pleurisy. 
It  is  far  more 
common  to  have 
the  chest  full  in 
chronic  than  in 
acute  pleurisy. 


Same  as  chron- 
ic pleurisy. 


Same  as  chron- 
ic pleurisy. 


Even  more  dis- 
placement of  the 
heart  generally  than 
in  chronic  pleurisy, 
it  pulsating  some- 
times even  beyond 
the  right  nipple.  If 
the  left  side  is  affect- 
ed, the  effusion  often 
receives  a  tangible 
and  visible  impulse 
from  the  heart's  beat; 
hence  the  term  "  pul- 
sating empyema." 

If  a  spontaneous 
perforation  takes 
place  through  the 
chest  walls,  and  the 
skin  remains  un- 
broken, the  tumor 
thus  formed,  besides 
fluctuating,  often  has 
a  strong  pulsation, 
synchronous  with  the 
systole,  simulating 
aneurism.  The  tu- 
mor may  also  in- 
crease and  decrease 
with  respiration. 


58 


THE  PHYSICAL  DIAGNOSIS 
TABLE   NO.   10,  Continued. 


INSPECTION   AND 
MENSURATION. 


PERCUSSION. 


RESPIRATION. 


HYDRO- 
THORAX. 


Although  there 
may  .he  more  liquid 
on  one  side  than  on 
the  other,  yet  there 
is  almost  never  one- 
sided dilatation  of 
the  chest  and  dis- 
placement of  the 
heart  and  medias- 
tinum. 


Flatness  or  dull- 
ness over  the  lower 
part  of  both  sides 
of  the  chest.  The 
line  of  flatness  al- 
most  always 
changes  with 
change  of  posture. 
Of  course  it  is  im- 
possible for  both 
pleural  cavities  to 
be  completely 
filled. 


As  in  pleurisy 
with  moderate  ef- 
fusion. There  is 
rarely,  however, 
well-marked  bron- 
chial respiration, 
as,  the  disease  "being 
bilateral,  sufficient 
compression  to  pro- 
duce bronchial  res- 
piration could  not 
often  be  compatible 
with  life. 


PULMONAET 

(EDEMA. 


More  or  less  dull- 
ness, generally  dif- 
fused equally  over 
the  back  of  the 
chest  on  both  sides, 
and  most  marked 
at  the  lowest  parts. 


Weakened  or 
suppressed. 

Rarely  well- 
marked  bronchial 
respiration. 


OF  DISEASES   OF   THE  LUNGS. 
TABLE  NO.  10,  Continued. 


VOCAL 
KESONANCE. 


PALPATION. 


REMARKS. 


No  exudation 
of  lymph  and 
therefore  no  fric- 
tion sounds. 


As  in  pleurisy 
with  moderate 
effusion. 


Vocal  f  remitus 
lessened  or  sup- 
pressed below  the 
level  of  the  liquid, 
but  increased  above. 


Hydrothorax  is 
bilateral  ;  while 
the  different 
kinds  of  pleurisy 
are  almost  with- 
out exception 
unilateral. 


Subcrepitant 
and  fine  bubbling 

rales. 


Variable. 


Vocal  fremitus  va- 
riable. 


Like  hydro- 
thorax,  pulmo- 
nary oedema  is  a 
result  of  structu- 
ral disease  of  the 
heart  or  kidney. 
Although  gen- 
erally bilateral, 
and  then  oftener 
found  in  the  pos- 
terior portions,  it 
may  be  unilateral 
and  extend  over 
one  lobe  or  a 
whole  lung. 


€0 


THE  PHYSICAL  DIAGNOSIS 
TABLE  NO.  10,  Continued. 


DISEASE. 

INSPECTION    AND 
MENSURATION. 

PERCUSSION. 

RESPIRATION. 

Expansion  of 

Flatness  at  the  base 

Suppressed     be- 

affected side  and 

of  the  chest  on   the 

low  the  level  of  the 

relative  mobility 

affected  side,  if  there 

liquid.    Feeble,  dis- 

impaired.      Ob- 

be enough  liquid  (se- 

tant or  suppressed 

literation     and 

rum  or  pus).      Over 

above,  unless  there 

sometimes  bulg- 

the upper  part  of  the 

is  a  free  communi- 

ing of  intercostal 

same  side  and  some- 

cation between  the 

depressions. 

times  extending  be- 

bronchial tubes  and 

yond    the     sternum, 

the   pleural  cavity 

tympanitic   resonance 

above   the  level  of 

almost  as  intense  as 

the     liquid,     when 

that  of  a  tympanitic 

there  may  be  heard 

abdomen.      This     is 

amphoric      respira- 

heard by  conduction 

tion,    limited   to  a 

even  below  the  level 

circumscribed   area 

of  the  liquid,  the  lat- 

near   the    perfora- 

ter often   extending 

tion,  which  is  gen- 

twice as  high  as  the 

erally  between   the 

line  of  flatness. 

third  and  sixth  ribs 

PNETJMO- 

The  tympanitic  res- 

on  the  postero-lat- 

HYDROTHO- 

onance  extends  over 

eral  surface  of  the 

RAX.     . 

the    whole     side,    if 

chest. 

there  be  only  a  small 

Bronchial    respi- 

amount    of     liquid. 

ration  over  the  con- 

Change   of     posture 

densed  lung  (which 

always,   in   this  dis- 

is    generally     also 

• 

ease,  changes  relative 

tuberculous),  at  the 

position    of    flatness 

top    of    the    chest 

and  tympanitic  reso- 

behind. 

nance.        Sometimes 

Respiration      on 

there  is  amphoric  res- 

healthy  side  exag- 

o nance.     Dullness 

gerated. 

from  the   condensed 

lung  may  sometimes 

be    detected    at    the 

summit  of  the  chest 

behind.    If  the  quan- 

tity of  air  or  gas  be 

vert/  large,  on  account 

of  the  extreme  tension 

there  may  be  tympa- 

nitic dullness. 

OF  DISEASES   OF  THE  LUNGS. 
TABLE  NO.  10,  Continued. 


61 


RA"LES. 


VOCAL 
RESONANCE. 


PALPATION. 


REMARKS. 


Metallic  tink- 
ling, and  splash- 
ing or  Hippo- 
cratic  succussion 
sound. 


Above  the  liquid 
amphoric  whisper, 
voice,  and  cough,  if 
there  is  amphoric 
respiration.  Or  the 
vocal  resonance  may 
be  feeble  or  wanting. 
Always  wanting  be- 
low the  liquid.  Me- 
tallic tinkling. 

Increased  vocal  res- 
onance or  bronchoph- 
ony  over  the  com- 
pressed lung  at  the 
top  of  the  chest  be- 
hind. 


Vocal  fremitus 
diminished  or 
suppressed. 

Displacement 
of  heart.  Fluc- 
tuation. Sense 
of  elasticity 
above  and  of  re- 
sistance below 
the  level  of  the 
liquid. 


When  this  dis- 
ease occurs,  it  is 
generally  a  com- 
plication of 
phthisis. 

The  relative 
proportion  of  air 
or  gas  and  water 
varies  in  different 
cases  and  in  the 
same  case  at  dif- 
ferent times,  es- 
pecially if  com- 
munication with 
the  external  air 
continues. 


THE  PHYSICAL  DIAGNOSIS 
TABLE  NO.  10,  Continued. 


INSPECTION    AND 

DISEASE. 

PERCUSSION. 

P.ESPI  RATION. 

MENSURATION. 

— 

As  in  the  preceding. 

Tympa  n  i  t  i  c 

Respiration     sup- 

resonance over  a 

pressed   where     the 

part  or  the  whole 

air  is,  or  it  may  be 

of    the   affected 

amphoric  if  there  is 

side,    sometimes 

free  communication 

PNEUMO- 

even    extending 

between    the    bron- 

TIIORAX. 

to   the   right  or 

chial  tubes  and  the 

left  beyond  the 

pleural  cavity.  Bron- 

sternum. 

c  h  i  a  1      respiration 

over  the  condensed 

lung.     Exaggerated 

on  the  healthy  side. 

There  is  a  character- 

Exaggera ted 

Weakened  or 

istic  deformity  of  the 

resonance  (some- 

suppressed over  the 

chest,  a  great  bulging 

times  called  ves- 

upper  lobes,   more 

of  the  whole  upper  part 
generally,  sternum  and 

i  c  u  1  o-t  y  m  p  a- 
nitic),    on    both 

so   usually   on    the 
left  than    on    the 

all. 

sides,    but    gen- 

right  side.      Inspi- 

The  antero-posterior 

erally  greater 

ratory  sound  short- 

diameter of  the   chest 

on  the  left.  It  is 

ened  and  expiration 

is     greatly    increased. 

heard      over     a 

remarkably     p  r  o- 

The  clavicles  are  ele- 

greater area  than 

longed,    though   of 

vated,  and  yet   almost 

the  vesicular  res- 

the   same     quality 

buried  up.     The  lower 

onance  in  health, 

as  in  health. 

parts  of    the    scapulae 

as  the  diaphragm 

sometimes  project.  The 

is  pushed  down 

entire  thorax  is  dragged 
upwards  as  one  piece  in 

and  the  heart  is 
more  or  less  com- 

inspiration, but  there  is 

pletely    covered 

little   or  no  expansion 

by  lung.    Owing 

of  the  chest,  because  the 

to      the     slight 

elasticity  of    the  lung 

movement  of  the 

EMPHY- 

tissue being  lost,  expi- 

lungs, this  area 

SEMA. 

ration  fails  to  empty  the 
chest,  and  there  is  little 

is  not  much  af- 
fected by  forced 

room  for  the  introduc- 

inspiration or  ex- 

tion of  fresh  air. 

piration. 

Respiratory     efforts 

If    the    lower 

labored  and   powerful, 

lobes     are     em- 

yet    the    breathing    is 

physematous,  the 

chiefly  abdominal,  and 

line    of    hepatic 

the  lower  part  of  the 

flatness  may  be 

chest  may  even  sink  in 

lowered    to    the 

during  inspiration.   De- 

ninth   or    tenth 

pression  above  clavicles 
in  inspiration. 

rib  on  the   per- 
pendicular mam- 

The    patient    often 

mary  line. 

stoops  from  antero-pos- 

terior curvature  of  the 

In      exceptional 

c:i-fs,  there  may  be 

spine. 

Rome    dullness  on 

In  a  few  cases  of  the 

percussion. 

variety  called    "senile 

atrophy  "  of  the  lung 

there  is  no  bulging. 

OF  DISEASES   OF   THE  LUNGS. 
TABLE  NO.  10,  Continued. 


63 


VOCAL 
RESONANCE. 


PALPATION. 


REMARKS. 


Diminished  or  sup- 
pressed where  the  air 
is,  or  amphoric  voice, 
whisper,  and  cough, 
if  there  is  amphoric 
respiration.  Vocal 
resonance  increased 
over  the  condensed 
lung,  or  even  bron- 
chophony. 


Vocal  fremitus 
diminished  or 
suppressed  where 
the  air  is,  but 
increased  over 
the  condensed 
lung.  Displace- 
ment of  heart. 


A  very  rare  dis- 
ease, air  or  gas 
without  liquid  almost 
never  being  found 
in  the  chest. 

Pneumo-hydrotho- 
rax  is  often  loosely 
called  pneumo-tho- 
rax,  however. 


If  bronchitis 
and  asthma  co- 
exist, bubbling 
rales,  and  oft- 
ener  sibilant 
and  sonorous 
rales. 


Vocal     resonance 
variable. 


Vocal  fremitus 
variable. 

Heart's  im- 
pulse lowered, 
sometimes  being 
felt  in  the  epi- 
gastrium instead 
of  in  the  prae- 
cordial  space. 

Chest  walls  un- 
usually elastic 
to  the  finger. 


In  the  great  ma- 
jority of  cases, 
vesicular  emphy- 
sema has  associ- 
ated with  it  chronic 
bronchitis.  It  is 
often  accompanied 
by  paroxysms  of 
asthma. 

Generally  a  bilat- 
eral disease,  al- 
though there  is 
usually  more  affec- 
tion of  the  left 
lung  than  of  the 
right. 


64 


THE  PHYSICAL  DIAGNOSIS 


TABLE  NO.  10,  Continued. 


INSPECTION   AND 
MENSURATION. 


PERCUSSION. 


RESPIRATION. 


ASTHMA. 


Often  a  bulg- 
ing of  the  upper 
part  of  the  chest, 
and  a  sinking  in, 
during  inspira- 
tion, of  the  lower 
part,  on  account 
of  the  emphy- 
sema which  gen- 
erally coexists. 

Labored  res- 
piration. 


Owing  to  the 
commonly  coexist- 
ing emphysema, 
there  is  generally 
exaggerated  per- 
cussion resonance, 
as  iu  that  disease. 


Diminished  or  sup- 
pressed. 

Sometimes  exag- 
gerated. 

Jerking. 


BRONCHITIS. 

(Affecting  the 
larger  tubes.) 


Healthy  r  e  s  o- 
nance  on  both 
sides  of  the  chest. 
A  negative  sign, 
but  a  good  one 
here. 

Rarely  a  slight  dull- 
ness at  the  lower  part 
of  the  back  of  the 
chest,  from  excessive 
secretion  which  can- 
not be  raised,  or  from 
collapse  of  pulmonary 
lobules  from  obstruc- 
tion of  bronchial 
tubes. 


In  many  cases  nor- 
mal. 

Sometimes  ob- 
scured by  the  rales, 
sometimes  weakened 
or  suppressed  over  a 
part  of  the  chest  by 
plugs  of  mucus  in 
tubes,  suddenly  reap- 
pearing after  cough- 
ing, sometimes  by 
thickening  of  the 
mucous  membrane ; 
but  from  this  latter 
cause  both  sides  are 
affected  alike. 


OF  DISEASES  OF  THE  LUNGS. 


65 


TABLE  NO.  10,    Continued. 


VOCAL 
RESONANCE. 


PALPATION. 


REMARKS. 


Loud  sibilant  and 
sonorous  rales  with  in- 
spiration and  expira- 
tion (the  sibilant, 
however,  being  more 
abundant  in  inspira- 
tion, and  the  sonorous 
in  expiration),  all  over 
the  chest  on  both 
sides  and  often  heard 
at  a  distance. 

Sometimes  bubbling 
rales  towards  the  close 
of  the  paroxysms  and 
for  several  days  after, 
when  they  cease,  un- 
less chronic  bronchitis 
coexists. 


The  physical 
signs  given  are 
those  of  a  parox- 
ysm. This  is 
generally  accom- 
panied by  a  tem- 
porary emphyse- 
matous  condition 
at  least,  and  by 
bronchitis. 

Regular  asth- 
matics often  have 
these  for  perma- 
nent complica- 
tions. 


On  both  sides  of  the 
chest,  especially  over 
the  lower  lobes  be- 
hind, sonorous  and  sib- 
ilant rales,  according 
to  the  size  of  the  tubes 
in  which  they  are  pro- 
duced, are  sometimes 
heard  alone,  before 
secretion  takes  place, 
and  after  this  mingled 
with  coarse  and  fine 
bubbling  rales.  In 
many  cases  no  rales 
are  heard  at  all,  and 
when  present  they  of- 
ten shift  their  posi- 
tion. The  moist  rales 
are  not  heard  unless 
the  mucus  is  unusual- 
ly thin  and  abundant, 
which  is  not  the  case 
in  many  instances. 
They  occur  oftener 
in  chronic  than  in 
acute  bronchitis,  be- 
cause in  the  former 
the  liquid  is  more  apt 
to  be  muco-purulent, 
and  therefore  pro- 
duces better  bubbles. 
They  occur  oftener 
also  in  young  chil- 
dren than  in  adults, 
because  the  former 
expectorate  less. 


Sometimes  a 
rhonchial  fremi- 
tus. 


A  bilateral  dis- 
ease. 


66 


THE  PHYSICAL  DIAGNOSIS 
TABLE  NO.  10,  Continued. 


INSPECTION  AND 
MENSURATION. 


PERCUSSION. 


RESPIRATION. 


CAPILLARY 
BRONCHITIS. 

(Including  catar- 
rhal  pneumonia.) 


If  there  is  con- 
siderable collapse 
of  pulmonary  lob- 
ules, with  emphy- 
sema, and  with  or 
without  catarrhal 
pneumonia,  the  up- 
per part  of  the 
chest  is  more  or 
less  expanded,  and 
the  lower  part  may 
even  sink  in  during 
inspiration. 


Undiminished  res- 
onance on  both 
sides  of  the  chest, 
except  sometimes 
when  there  is  col- 
lapse of  pulmonary 
lobules  with  or 
without  catarrhal 
pneumonia,  when 
there  may  be  some 
circumscribed  dull- 
ness over  dissemi- 
nated portions  of 
the  lung,  especially 
over  the  lower 
lobes  behind,  and 
exaggerated  reso- 
nance in  other 
parts,  especially 
the  upper  part  of 
the  chest  in  front, 
if  emphysema  co- 
exists. 


Respiration  weak- 
ened or  obscured  by 
rales.  If  solidifica- 
tion from  collapse 
coexists  (with  or 
without  catarrhal 
pneumonia),  bron- 
cho-vesicular or 
bronchial  or  weak- 
e  n  e  d  respiration 
over  such  parts.  If 
emphysema  coex- 
ists, weak  or  sup- 
pressed inspiration 
in  front  above,  and 
expiration  length- 
ened. 


PLASTIC 

BRONCHITIS. 

(Pseudo-mem- 
branous.) 


No  dullness  un- 
less from  collapse, 
or  from  great 
quantity  of  liquid 
in  bronchi. 


There  may  be 
suppression  of  res- 
piration over  parts 
of  the  chest  from 
the  exudation  or 
from  collapse ;  or 
broncho  -  vesicular 
or  bronchial  respi- 
ration from  col- 


OF  DISEASES  OF  THE  LUNGS. 
TABLE  NO.  10,  Continued. 


67 


RALES. 

VOCAL, 

PALPATION. 

REMARKS. 

RESONANCE.  • 

Subcrepitant  rales 

If      solidifica- 

If    solidifica- 

A bilateral  dis- 

•uniformly present  on 

tion     from    col- 

tion   from    col- 

ease.    Inflamma- 

lx>th sides  of  the  chest, 
with    either    or  both 

lapse  exists,  with 
or  without  catar- 

lapse  exists,  with 
or  without  catar- 

tion  of  the  larger 
tubes     generally 

respiratory    acts,    es- 
pecially     over      the 

rhal  pneumonia, 
increased    vocal 

rhal  pneumonia, 
increased    vocal 

coexists.      Capil- 
lary bronchitis  is 

lower    third    of    the 

resonance  or 

fremitus       over 

sometimes  attend- 

chest behind. 

broncho  phony 

such  parts. 

ed  with  collapse 

Sibilant  and   sono- 

over such  parts. 

o  f      pulmonary 

rous,    especially  s  ibi- 

lobules    and    ca- 

lant    rales,    and    also 

tarrhal   pneumo- 

fine and  coarse  bubbling 

nia,  especially  in 

rales  may  be  heard  all 

infants  or  in  aged 

over  the  chest  on  both 

or  feeble  persons. 

sides  when  the  smaller 

Collapse,   by  the 

and  larger  tubes  are 

law  of    compen- 

also affected. 

sation,  generally 

gives      rise      to 

emphysema      in 

other  portions  of 

the  lung. 

Sonorous  and    sibi- 
lant   rales     on     both 

As  in  the  pre- 
ceding. 

As  in  the  pre- 
ceding. 

A  rare  disease. 
The  .fibrinons 

sides. 

exudation     com- 

Subcrepitant     rales 

mences     in     the 

limited  to  certain  por- 

minute  branches 

tions  of  chest.    Also 

and  extends  up- 

bubbling rales. 

wards.    A  few  or 

There  may  be  tem- 

many tubes  may 

porary  suppression  of 

be  affected.    Col- 

rales over  parts  of  the 
chest  from  the  exuda- 

lapse  of    pulmo- 
nary lobules  may 

tion,  or  more  lasting 

occur   from    ob- 

suppression from  col- 

struction. 

lapse. 

Bilateral     dis- 

ease.   Either 

acute  or  chronic. 

68 


THE  PHYSICAL  DIAGNOSIS 
TABLE  NO.  10,  Continued. 


INSPECTION  AND 
MENSURATION. 


PERCUSSION. 


RESPIRATION. 


ACUTE  LOBAR 

OK  CROUPOUS 

PNEUMONIA. 

First  Stage. 
(Congestion.) 


Sometimes  cos- 
tal movements 
on  affected  side 
dimiuis bed  on 
account  of  pain. 


There  may  be  a  slight 
dullness. 


We  akene  d 
somewhat  over 
the  congested 
lobe. 


Second  Stage. 

(Hepatization.) 


Costal  move- 
ments dimin- 
ished on  affected 
side  (especially 
if  the  whole  lung 
be  inflamed),  and 
increased  on  the 
other  side. 

There  may  be 
in  some  cases  a 
slight  increase  by 
measurement. 


Over  the  affected  lobe 
or  lobes  increased  sense 
of  resistance  and 
marked  dullness,  some- 
times even  amounting 
to  flatness.  The  inter- 
lobar  fissure  can  be  dis- 
tinctly mapped  out  by 
percussion,  if  one  or 
two  lobes  of  the  affected 
lung  remain  unaffected, 
the  latter  giving  forth 
an  exaggerated  reso- 
nance. In  such  cases 
the  resonance  over  the 
healthy  lung  is  i n- 
creased,but  not  so  much 
as  over  these  unaffected 
lobes. 

In  some  cases,  instead  of 
the  usual  dullness  there  may 
be  tympanitic  or  cracked- 
metal  or  amphoric  reso- 
nance over  part  of  an  upper 
solidified  lobe,  this  quality 
coming  from  the  air  in  thie 
trachea  or  bronchi,  con- 
ducted by  the  solidification ; 
also  sometimes  at  the  base 
of  the  chest,  if  affected,  be- 
ing conducted  upwards  from 
the  stomach  or  colon. 


Broncho-vesicu- 
lar followed  by 
bronchial  respira- 
tion, as  solidifi- 
cation increases. 

Exagg  crated 
on  healthy  side. 


OF  DISEASES  OF  THE  LUNGS. 
TABLE  NO.  10,  Continued. 


69 


VOCAL  RESONANCE. 


PALPATION. 


REMARKS. 


Generally,  but 
not  invariably,  the 
ere  pit  ant  rale. 
When  it  does  occur, 
it  is  pathognomonic. 

Rarely  dry  and  moist 
bronchial  rales  from 
accompanying  circum- 
scribed bronchitis,  or  a 
friction  sound  from 
secondary  pleurisy. 


Generally  a  uni- 
later al  disease. 
More  common  in  a 
lower  lobe,  espe- 
cially on  the  right 
side.  When  so  situ- 
ated, the  physical 
signs  are  best  heard 
in  the  infra-scapu- 
lar and  infra-axil- 
lary regions. 


Crepitant  rale  dis- 
appears, but  occa- 
sionally it  persists 
even  in  this  stage,  a 
few  air-cells  here 
and  there  not  being 
filled  with  exuda- 
tion. 


Rarely   moist    bron- 
chial rales. 


Increased  vocal 
resonance  and  in- 
creased bronchial 
whisper,  followed 
by  bronchophony  and 
whispering  br  on- 
chophony,  as  solidi- 
fication increases. 

Occasionally  pec- 
toriloquy  and 
whispering  pecto- 
riloquy. 


Vocal  fremi- 
tus  generally 
increased  over 
affected  por- 
tion, but  some- 
times dimin- 
ished, and  oc- 
casionally ab- 
sent, owing  to 
plugging  of 
bronchi  or 
pleuritic  effu- 
sion. 


Sometimes  the 
heart's  sounds  are 
transmitted  with 
peculiar  dist  i  n  c  t- 
ness  through  the 
solidification,  some- 
times not. 


70 


THE  PHYSICAL  DIAGNOSIS 
TABLE   NO.    10,  Continued. 


DISEASE. 

INSPECTION  AND 
MENSURATION. 

PERCUSSION. 

RESPIRATION. 

CROUPOUS 
PNEUMONIA. 

Third  Stage. 
(1.)  Resolution. 

G  r  a  d  u  a  1  re- 
turn to  the  nor- 
mal cond  i  t  i  o  n, 
and  after  recov- 
ery even  contrac- 
tion may  occur 
in  some  cases. 

Dullness  grad- 
ually disappears. 
A  little,  however, 
often  remains  for 
a  long  time. 

The  bronchial 
merges  into  the  bron- 
cho-vesicular respira- 
tion, which  is  followed 
for  some  time  after 
recovery  by  weakened 
respiration. 

or 

(2.)  Purulent 
infiltration. 

• 

Dullness  con- 
tinues, and  be- 
comes more 
marked. 

Bronchial  respira- 
tion, or  feeble  or  sup- 
pressed respiration. 

CATARRHAL 
PNEUMONIA. 

Already 

explained  in 

connection  with 

(Lobular  or  broncho- 
pneumonia.) 

INTERSTITIAL 

OR 

CHRONIC  PNEU- 
MONIA, 

OR 

FIBROID  PHTHI- 

Difference in 
the  relative  cos- 
tal moveme  n  t  s 
on  the  two  sides, 
and  after  a  while 
contract  ion  of 
the  affected  lobe. 

Marked  dull- 
ness. 

Occas  i  o  n  a  1  1  y  a 
tympanit  i  c  r  e  s  o- 
nance. 

Bronchial  or  bron- 
cho-vesicular. 

SIS. 

OF  DISEASES  OF  THE  LUNGS. 
TABLE  NO.  10,  Continued. 


71 


RALES. 

VOCAL 

PALPATION. 

REMARKS. 

RESONANCE. 

Subcrepitant 

Bronchophony 

Increa  s  e  d  v  o- 

rale  appears,  with 

and    whispering 

cal  fremitus,  fol- 

sometimes a  few 

bronchop  h  o  n  y, 

lowed  by  the  nor- 

fine   and    coarse 

followed    by  in- 

mal. 

bubbling  rales. 

creased     vocal 

Crepitant  rale  re- 

resonanc e    and 

- 

turns. 

increased    bron- 

chial   wh  i  s  pe  r, 

and  this  by  nor- 

mal vocal  reson- 

ance and  whisper. 

Fine  and  coarse 

Weak    b  r  o  n- 

Vocal  fremitus 

If,  as  very    rarely 

bubbling    rales 

chophony  or  di- 

variable. 

happens,     an    abscess 

generally    in 
abundance. 

minished     vocal 
resonance. 

forms  and  discharges; 
it  may  give  rise  to  the 

same    physical    signs 
as  a  phthisical  cavity 

(which  see). 

Capillary 

Bronchitis. 

Limited  to  lobules 

scattered    through 

lung     substance     i  n 

patches    varying    i  n 

size  from  a  hemp  seed 

to  an  egg,  or  larger. 

Fine  and  coarse 

Increased  vo- 

Increased   vo- 

Called also   Cirrho- 

bubbling rales, 

cal  reso  nance 

cal  fremitus. 

sis  of    Lung.    It 

also  sibilant  and 

and   incre  a  s  e  d 

leads    to    contraction 

sonorous  rales. 

bronchial    whis- 

of the  lung  and  dila- 

per. 

tation  of  the  bronchi, 

Bronchophony 

and  is  always  accom- 

and   whispering 

panied  by  bronchitis. 

bronchophony. 

A  unilateral  disease. 

Occurs  among   stone 

masons,  grinders,  etc. 

This  disease   is  "  the 

anatomical    basis    of 

almost  all  pulmonary 

phthisis." 

72 


THE  PHYSICAL  DIAGNOSIS 
TABLE  NO.   10,  Continued. 


INSPECTION   AND 
MENSURATION. 


PERCUSSION. 


RESPIRATION. 


ACUTE 

MlLJARY 

TUBERCULO- 
SIS. 


When  one  lung 
is  affected  a  little 
more  than  the 
other,  there  may 
be  a  slight  excess 
of  dullness  in  the 
former.  But  oft- 
ener  there  is  no 
notable  dullness  on 
either  side,  the 
granulations,  even 
when  very  numer- 
ous, remaining  iso- 
lated. 


PHTHISIS. 

First  Stage. 
(Incipient.) 


Some  dullness,  es- 
pecially if  the  de- 
posit "be  at  all 
superficial,  at  the 
summit  of  the  chest 
on  one  side  (more 
often  the  left),  in 
front  or  behind. 

There  may  be 
vesiculo-tympanitic 
resonance  at  the 
apex  from  second- 
ary lobular  emphy- 
sema. 

Remember  the 
possible  very  slight 
dullness  in  health 
on  the  right  side. 
It  is  in  connection 
with  the  diagnosis 
of  incipient 
phthisis  that  this 
fact  becomes  of  the 
most  importance. 
Any  dullness, 
however  slight,  at 
the  left  apex  is  al- 
ways abnormal. 


Respiration 
weakened  or  bron- 
cho-vesicular, occa- 
sionally jerking. 

[There  may  be 
abnormal  trans- 
mission of  the 
heart  sounds 
(available  in  the 
infra-clavicular  re- 
gion), denoting  a 
deposit  on  the  right 
side,  if  the  first 
sound  be  heard 
better  here  than  on 
the  left ;  and  on 
the  left  side,  if  the 
second  sound  be 
heard  better  here 
than  on  the  right.] 


OF  DISEASES  OF  THE  LUNGS. 
TABLE  NO.   10,   Continued. 


73 


VOCAL 
RESONANCE. 


PALPATION. 


REMARKS. 


Subcrepitant,  fine  and 
coarse  bubbling,  and 
sibilant  and  sonorous 
rales  in  different  places 
all  over  both  sides. 


The  trouble 
is  apt  to  be 
found  about 
equally  d  i  f  - 
fused  in  both 
lungs.  This 
disease  is  lia- 
ble to  be  con- 
founded with 
typhoid  fever. 


There  may  be  one  or 
more  of  the  following 
kinds  of  rales  :  — 

1.  Subcrcpitant,    indi- 
cating a  circumscribed 
capillary   bronchitis 
about  the  deposit. 

2.  Crepitant,  here  oft- 
en  called   crackling,   in- 
dicating a  circumscribed 
pneumonia. 

3.  Rubbing      friction 
sounds,  here  often  called 
crumpling,   indicating  a 
circumscribed  dry  pleu- 
risy. 

4.  Sibilant  rales,  indi- 
cating a  spasm  of  the 
tubes,  or  circumscribed 
bronchitis. 

All  these  rales  derive 
their  significance  from 
being  heard  at  the  apex 
(oftener  the  left). 


Increased  bron- 
chial whisper. 

Increased  vo- 
cal resonance. 

Remember  the 
possible  normal  dis- 
parity. 


Increased   vo- 
cal fremitus. 


74 


THE  PHYSICAL  DIAGNOSIS 
TABLE  NO.  10,  Continued. 


INSPECTION   AND 

DISEASE. 

PERCUSSION. 

RESPIRATION. 

M  ENSURATION. 

Some  flattening 

Dullness,  more  or 

Bronchial  or  bron- 

* 

and    deficient    ex- 

less, at  upper  part 

c  h  o-v  esicular  or 

pansion  of  the  up- 

of chest  on  affect- 

weakened   respira- 

per part  of  chest 

ed  side. 

tion.     Occasionally 

on   one   side. 

Or     tympanitic 

jerking.        (Abnor- 

PHTHISIS. 

Marked      diminu- 
tion in  size  of  chest 

resonance     (c  o  n- 
ducted  from  bron- 

mal transmission  of 
heart  sounds.) 

Second  Stage. 

by  mensuration. 

chi,  as  there  are  no 
cavities  yet). 

There    may    be 

exaggerated    reso- 

nance from    coex- 

isting lobular  em- 

physema. 

Extra  ordinary 
prominence  of  the 

Ti/mpanitic  reso- 
nance within    cir- 

Caiwnous   respi- 
ration, especially  af- 

clavicles from  the 

cumscribed  spaces. 

ter  an  abundant  ex- 

falling in  of  tipper 

Occasionally 

pectoration.    If  the 

parts  of  lung,  and 

cracked-metal     or 

cavities    are    quite 

deficient  e  x  p  a  n- 

amphoric    reso- 

small,   the  cavern- 

Third Stage. 

sion. 
Still  greater  dim- 

nance. 
Dullness      over 

ous  respiration  may 
be  drowned  out  by 

(Cavernous.) 

inution  in  size  of 
chest  by  mensura- 

the same  space,  if 
the  cavity  is  full  of 

the      neighboring 
bronchial     respira- 

tion. 

morbid     products, 

tion,    or  combined 

as,    e.   g.,    in    the 

with  it,  forming  a 

morning   before 

kind     of     broncho- 

copious  expectora- 

cavernous   respira- 

tion. 

tion.     Rarely    am- 

phoric respiration. 

There    may     be 

Generally    dull- 

Bronchial, if  the 

some  depression  of 

ness  from  the  con- 

tubes are  cylindric- 

the chest  over  the 

densed    and     con- 

al and  unobstruct- 

places affected. 

tracted    parenchy- 

ed. 

ma,  and  also  from 

Cavernous        o  r 

accumulation      of 

amphoric,  if   saccn- 

DILATATION 

mucus. 
Sometimes  tym- 

lar   and    large 
enough. 

OF   THE 

BRONCHI. 

panitic  or  amphor- 

ic resonance,  if  the 

(Bronchiectasis.) 

tubes  are  free  from 
morbid  products. 

OF  DISEASES  OF  THE  LUNGS. 
TABLE   NO.   10,    Continued. 


RALES. 

VOCAL 

PALPATION. 

REMARKS. 

RESONANCE. 

Fine  and  coarse  bub- 

Increased 

Increased    vocal 

The   accompany- 

bling rales,  from  soft- 

vocal reso- 

fremitus. 

ing  signs    are    ob- 

ened deposit  or  from 

nance     and 

served   on  the  side 

accompanying     c  i  r  - 

whisper,   or 

first  affected,   gen- 

cumscribed bronchitis, 

bronchophony 

erally  at  the  apex. 

generally  heard  bet- 

and whisper- 

By    this      time, 

ter  in    the    morning 

ing    bron- 

however, signs  de- 

before much  expecto- 

chophony. 

noting    a    less   ad- 

ration.    Also   sibilant 

O  c  c  a  s  ion- 

vanced  condition  of 

and     sonorous     rales, 

ally      bron- 

the  disease  may  be 

friction    sounds,    and 

choph  o  n  i  c 

heard  at  the  apex 

crepitant  and  subcrepi- 
tant  rales  may  be  heard. 

pectoriloquy. 

of  the  other  side. 

Gurgling. 

Sometimes 

Increased    vocal 

These  cavernous 

Very  rarely  metal- 
lic tinkling. 

caver  nous 
pectoriloquy 

fremitus  when  the 
cavity     is      large, 

signs  (to  be  sought 
for  especially  in  the 

and      whis- 

superficial, and  has 

upper  part   of   the 

pering    pec- 

free communication 

lung)  •  often    have 

toriloquy. 

with   the   bronchi. 

in      their     vicinity 

Amphoric 

Sometimes    gur- 

many of  the  signs 

voice    when 

gling     fremitus. 

of  solidification  al- 

there is  arrt- 

When  the   disease 

ready  mentioned. 

phoric    res- 

exists    principally 

piration. 

in    one  lung,    the 

shrinking    of    this 

lung  sometimes 

drags  the  heart  out 

of     place.     Pulsa- 

tion   detected    by 

palpation. 

Bubbling  rales  from 

Increased 

Increased   vocal 

Usually      affects 

mucus      in      dilated 

vocal     reso- 

fremitus. 

many  bronchi,  and 

tubes;  sometimes  even 

nance     and 

occurs      in       both 

gurgling,   if  there   is 

bronchoph  - 

lungs.     Most  com- 

considerable     dilata- 

ony. 

mon   in  the    lower 

tion. 

Sometimes 

lobos  and  the  mid- 

pectoril- 

dle  lobe  of  the  right 

oquy. 

lung.    Follows 

bronchitis,  collapse 

of   pulmonary   lob- 

ules, pleurisy,  and 

pneumonia,      espe- 

cially      interstitial 

pneumonia.     T  h  e 

dilatation    may    be 

of  three  varieties,  — 

cylindrical,     f  u  s  i- 

form,  or  saccular. 

76 


THE  PHYSICAL  DIAGNOSIS 
TABLE  NO.  10,  Continued. 


INSPECTION  AND 
MENSURATION. 


PERCUSSION. 


RESPIRATION. 


CABCINOMA 

OF 
LUNG. 


Diminished  costal 
motion  Flattening 
and  contraction  of 
the  affected  side  (if 
infiltrated). 

Or  the  growth  may 
be  so  great  (perhaps 
four  or  five  pounds) 
as  to  enlarge  the  side. 

Effacement  of  in- 
tercostal depressions, 
if  pleuritic  effusion 
ensue. 


Dullness,  often 
extending  beyond 
the  median  line, 
with  increased  re- 
sistance, uniformly 
extending  over  a 
part  or  the  whole 
of  a  lung,  if  infil- 
trated, but  scat- 
tered, if  there  are 
nodules  large 
enough  to  produce 
dullness. 


Bronchial  or 
feeble  or  sup- 
pressed. (Sup- 
pressed by  press- 
ure of  cancerous 
deposit  on  a  large 
bronchus.) 

If  only  one 
lung  is  affected, 
exaggerated  res- 
piration over 
the  healthy  lung. 


There  may  be  a 
bulging  or  even  per- 
foration of  the  ribs 
and  sternum,  with 
diminished  respira- 
tory movements. 

Enlargement  of 
chest  not  as  uniform 
as  when  enlarged  by 
liquid.  Distention  of 
superficial  thoracic 
veins  ;  or  of  those  of 
one  or  both  upper 
extremities  with 
(Especially  alien-  ,  oedema;  or  of  those  of 
one  or  both  sides  of 
the  neck  (significant 
if  there  is  no  tricus- 
pid  regnrgitrttion  or 
dilatation  of  the  right 
heart). 

Local  pulsation, 
synchronous  with 
heart's  systole,  some- 
times visible  in  aneu- 
rism. 


INTRA- 
THORACIC 
TUMORS. 


There  may  be 
dullness  or  flat- 
ness over  the  tu- 
rn o  r  (and  over 
pleuritic  effusion 
or  compressed  lnn<r 
if  they  coexist). 
The  dullness  over 
an  aneurism  or 
mediasn'nal  tumor 
always  extends  »/>- 
icn rr/s  and  to  the 
right  or  left ;  in 
aneurisms  espe- 
cially to  the  right. 
There  must  not  l>e 
too  forcible  percus- 
sion over  aneurism. 


Over  the  tumor 
weakened  or  sup- 
pivssed  from 
pressure,  and 
bronchi  nl  over 
compre-sed  lung, 
if  there  be  any. 


OF  DISEASES  OF  THE  LUNGS. 
TABLE  NO.  10,  Continued. 


77 


RALES. 

VOCAL 

PALPATION. 

REMARKS. 

RESONANCE. 

Bubbling  rales, 

Increased 

Vocal  fremitus  at 

A  rare  disease. 

if  softening  takes 

vocal    reso- 

first increased,  then 

Usually      encepha- 

place,  or  if  there 

nance     and 

diminished. 

loid    and    associated 

is   secondary 

bronchoph  - 

with  mediastinal  can- 

bronchitis. 

ony. 

cer.     There  are   two 

varieties  :  — 

1.  Secondary   nodu- 

lar deposit,  oftener  af- 

fecting both  lungs,  the 

nodules     varying    in 

size  from  a  pea  to  an 

orange.    If  few,  small, 

and     scattered,    they 

may  not  give   rise  to 

any  physical  signs. 

2.  Primary  infiltra- 

tion into  the  air-cells, 

usually   affecting  one 

lung.     Pleuritic  effu- 

sion   often     coexists. 

Softening  and  exca- 

vation     may      take 

place. 

There  may  be 

Vocal  res- 

Vocal fremitus  di- 

These tumors  are, 

bubbling  rales 

onance    va- 

minished     or      sup- 

in the  great  majority 

from     secondary 

riable. 

pressed   over  tumor. 

of    cases,    aneurisms  ; 

bronchitis,  or 

Bronchoph- 

Increased  over  com- 

but    sometimes     are 

from      softening 

ony    over 

pressed  lung  and  pri- 

cancerous, fibrous,  or 

if  the    tumor  is 

c  o  m  pressed 

mary  bronchi. 

fatty    tumors,  which 

cancerous. 

lung  tissue, 

Heart      pulsations 

generally   start   from 

There  is  often, 

if    there  be 

may  often  be  felt  out 

the  mediastinum. 

but   not    always, 

any. 

of    place    in    conse- 

They     often      exert 

heard  over  an  an- 

quence of  the  press- 

great    pressure     (to 

eurism  a  systolic 

, 

ure.   The  arteries  on 

their     injury,     of 

murmur,   soft    or 

one  side  may  be  com- 

course) on  the  heart, 

harsh  or  roaring, 

pressed  more  than  on 

lungs,  nerves,  or  ves- 

and   of  variable 

the  other.     Over  an- 

sels, with    character- 

intensity.    Rare- 

eurism an  impulse  is 

istic  symptoms.     Tu- 

ly there  may  be 

felt  synchronous  with 

mors  may  be  on  one 

heard  also  a  dias- 

the    heart's    systole, 

or  both  sides  of  chest. 

t  o  1  i  c  murmur, 

sometimes     stronger 

Pleuritic  effusion  may 

caused     by     the 

even  than  over    the 

result,    also    collapse 

passage  of  blood 

heart,      sometimes 

of  pulmonary  lobules 

out  of  the  sac. 

double,  either  throb- 

or oedema.     A  n  e  n- 

bing  or   undulating. 

risms  arise  most  com- 

Often a,  purring  thrill 

monly  from    the   as- 

is felt,  generally  cir- 

cending    portion     of 

cumscribed,         but 

the  arch  of  the  aorta. 

sometimes      diffused 

over  a  large  portion 

of  the  chest. 

78 


THE  PHYSICAL  DIAGNOSIS 
TABLE  NO.  11. 


AUSCULTATION. 


PERCUSSION. 


THE 

HEALTHY 
HEART. 


When  heard  over  the  apex,  the 
two  healthy  heart  sounds  may  be 
roughly  represented  by  a  trochee 
with  dots  marking  the  pauses, 
thus  : ^  . . .  The  first  or  sys- 
tolic is  accented,  long,  booming 
and  of  low  pitch,  and  the  second  or 
diastolic  sound  is  short  and  valvu- 
lar. At  the  base  of  the  heart  the 
two  sounds  may  more  nearly  be  rep- 
resented by  an  iambus  ^  .  —  .  . ., 
the  second  sound  being  here  ac- 
cented and  as  long  as,  if  not  longer 
than,  the  first  sound,  and  more  in- 
tense. This  is  because  the  booming 
quality,  caused  by  the  "  element  of 
impulsion "  or  "  muscular  ele- 
ment," is  not  transmitted  so  far 
as  the  valvular  element  of  the  first 
sound. 


The  space  on  the  surface 
of  the  chest  beneath  which 
the  heart  lies  is  called  the 
prcecordia,  or  prajcordial 
region.  That  part  of  the 
praecordia  which  is  uncov- 
ered of  lung  is  called  the  su- 
perficial cardiac  space,  and 
the  rest,  where  lung  tissue 
intervenes  between  the 
heart  and  chest  walls,  is 
called  the  deep  cardiac 
space.  The  boundaries  of 
each  of  these  spaces  must 
be  carefully  memorized. 
They  are  well  shown  on 
Plate  I. 

The  dullness  over  the 
deep  cardiac  space,  though, 
distinct,  is  of  course  much 
less  than  that  over  the  su- 
perficial cardiac  space. 


PERICARDI- 
TIS. 

First  Stage. 

(Exudation  of 
fibrin.) 


A  characteristic  friction  sound, 
often  lasting  a  few  hours  only,  but 
sometimes  for  a  few  days,  pro- 
duced by  the  rubbing  together  of 
the  inflamed  and  roughened  peri- 
cardial  surfaces  in  the  systolic  and 
diastolic  movements  of  the  heart. 
It  is  either  single  or  double,  strictly 
accompanying  or  independent  of 
the  heart  sounds,  always  super- 
ficial, and  usually  restricted  to  the 
praecordial  space,  —  sometimes* 
even  to  a  part  of  it  only.  Heard 
with  the  greatest  intensity  on  the 
left  edge  of  the  sternum  on  a  level 
with  the  fourth  rib.  Quality  graz- 
ing, crumpling,  creaking,  or  rasp- 
ing, and  either  feeble  or  loud.  In- 
tensity increased  by  bending  the 
body  forward  so  that  the  heart  is 
brought  nearer  the  chest  walls. 
Also  increased  by  firm  pressure 
with  the  stethoscope ;  also  by  a  full 
inspiration,  the  pericardial  surfaces 
being  forced  nearer  together  by  the 
expanded  lung.  A  single  sound 
may  be  made  double  in  this  way. 


OF  DISEASES  OF  THE  HEART. 
TABLE  NO.  11. 


79 


INSPECTION. 


PALPATION. 


The  apex  i  m- 
pulse  of  the  healthy 
heart  can  f  r  e- 
quently,  hut  not  al- 
ways, be  seen  in  the 
same  place  in  which 
it  is  felt. 


The  healthy  apex  beat  in  the  sit- 
ting or  standing  posture  is  felt  in 
the  fifth  intercostal  space,  but  often 
in  the  fourth  when  lying  on  the 
back.  It  is  felt  over  an  area  an 
inch  in  diameter,  from  half  an  inch 
to  two  inches  to  the  right  of  the 
linea  mammalis  (a  vertical  line 
drawn  through  the  left  nipple),  and 
about  three  inches,  on  an  average, 
to  the  left  of  the  median  line.  When 
lying  on  the  right  side,  the  centre 
of  the  area  is  about  half  an  inch 
nearer  the  sternum,  and  when  lying 
on  the  left  side  it  is  felt  on  the  linea 
mammalis.  In  some  persons  the 
apex  beat  cannot  be  felt  at  all,  espe- 
cially when  lying  on  the  right  side. 
It  is  felt  better  when  on  the  back, 
still  better  when  sitting,  and  best 
of  all  when  on  the  left  side. 


For  purposes  of 
compari son,  the 
signs  of  the 
healthy  heart  are 
placed  here. 

A  thorough 
knowledge  of  the 
healthy  heart  is  an 
absolutely  indispen- 
sable prerequisite  to 
an  understanding  of 
the  diseased  organ. 


Irrit  able  and 
forcible  action  of 
heart. 


Forcible  action  of  heart  and  fric- 
tion fremitus. 


Endocarditis  with 
its  physical  signs 
often  coexists. 
Rheumatic  pericar- 
ditis, which  occurs 
perhaps  once  in 
every  six  cases  of 
rheumatic  fever, 
is  almost  always  ao- 
companied  by  endo- 
carditis. 


80 


THE  PHYSICAL  DIAGNOSIS 
TABLE  NO.  11,  Continued. 


DISEASE. 


AUSCULTATION. 


PERCUSSION. 


PERICAR- 


Second 
Stage. 

(Serous  ef- 
fusion.) 


ENDO- 
CARDI- 
TIS. 


Friction  sounds  generally  (but 
not  invariably)  disappear  when 
the  effusion  becomes  considera- 
ble ;  often  remaining,  however, 
at  the  base  of  the  heart  near  the 
large  vessels,  and  sometimes  be- 
ing distinctly  heard  all  over  the 
praecordia,  in  spite  of  the  effu- 
sion, by  bending  the  body  for- 
wards. Heart  sounds,  especially 
the  first,  now  feeble  and  distant, 
or  absent  altogether.  Absence 
of  respiratory  murmur  and  vocal 
resonance  over  the  enlarged  area 
caused  by  the  distention  of  the 
pericardial  sac,  the  distention 
pushing  the  lungs  to  the  right 
and  left. 

During  absorption  the  friction 
sounds  reappear  and  may  last  a 
week  or  more ;  and  the  heart 
sounds  become  more  distinct. 


With  large  effusion,  the  area  of 
prsecordial  dullness  is  greatly  in- 
creased vertically  and  laterally, 
and  in  the  upright  posture  it  be- 
comes pyramidal  in  shape,  corre- 
sponding to  the  form  of  the  dis- 
tended sac,  whose  base  is  near  the 
sixth  intercostal  space,  and  apex 
near  the  sternal  notch,  and  which 
may  extend  laterally  almost  from 
one  nipple  to  the  other. 

In  chronic  pericarditis  with  very 
large  effusion  and  dilatation  of  the 
sac,  the  dullness  or  flatness  may 
extend  nearly  to  the  axillary  and 
infra-axillary  regions  on  each  side. 
The  dullness  from  the  liquid  ex- 
tends below  the  point  of  the  apex 
beat.  The  anterior  portion  of  the 
sac  is  mostly  uncovered  of  lung 
and  in  contact  with  the  chest  walls. 
When  the  patient  lies  down,  the 
lateral  diameter  of  dullness  is  in- 
creased at  the  expense  of  the  ver- 
tical. 

If  the  effusion  is  small,  there  is 
merely  an  increase  in  the  lateral 
diameter  of  dullness  at  the  lower 
portion  of  the  praecordial  region 
in  the  upright  posture. 

Gradual  diminution  of  the  area 
of  dullness  as  convalescence  ap- 
proaches. 


A  systolic  murmur,  generally 
soft  and  feeble,  due  to  thickening 
or  roughening  of  the  inflamed  en- 
docardium, heard  sometimes  at 
the  aortic  orifice,  but  usually  at 
the  apex.  The  swollen  mitral 
valves  with  shortened  chords  may 
be  slightly  insufficient,  but  usu- 
ally the  murmur  is  mitral  non-re- 
gurgitant,  caused  by  intra-ventric- 
ular  roughness. 

Auscultation  of  the  heart  should  be 
practiced  at  the  beginning  of  every  case 
of  rheumatic  fever,  to  make  sure  that 
there  is  no  old  valvular  lesion  which 
might  be  mistaken  for  a  recent  endo- 
carditis. If  there  be  an  old  valvular 
murmur,  there  will  be  more  or  less 
cardiac  hypertrophy,  and  the  murmur 
may  be  loud  and  rough. 


OF  DISEASES   OF  THE  HEART. 
TABLE  NO.    11,  Continued. 


81 


INSPECTION. 


PALPATION. 


Arching  forward  of 
the  prascordial  region 
(mostly  in  young  peo- 
ple,, whose  costal  carti- 
lages are  pliable),  often 
extending  from  the  sec- 
ond to  the  sixth  intercos- 
tal space.  The  effusion, 
if  large,  restrains  the 
respiratory  movem  e  n  t 
on  the  left  side. 


The  point  of  the  apex 
beat  raised  and  carried 
to  the  left  of  its  normal 
position.  Friction 
fremitus  disappears. 

Apex  beat  feeble,  or 
imperceptible,  if  effu- 
sion is  large. 


Usually  the  effusion  lasts 
about  a  week  or  ten  days 
in  acute  cases. 

Hydropericardium  has 
physical  signs  which  do 
not  materially  differ  from 
those  of  pericarditis,  ex- 
cept that  there  is  no  fric- 
tion sound. 


At  first  the  area  of 
the  visible  impulse  of 
the  heart  is  increased, 
but  later  it  is  apt  to  be 
indistinct. 

Irregular  beating. 


At  first  violent  and 
excited  action,  after- 
ward weakened. 


Occurs  in  the  great  ma- 
jority of  instances  as  a  sec- 
ondary affection  in  the 
course  of  acute  articular 
rheumatism.  It  is  more 
common  than  pericarditis, 
with  which  it  is  often  asso- 
ciated, being  far  oftener 
observed  without  pericar- 
ditis than  the  latter  is  with- 
out it. 

It  may  occur  in  the  es- 
sential and  exanthematous 
fevers,  in  pyemia,  Bright's 
disease,  diphtheria,  etc. 


82 


THE  PHYSICAL  DIAGNOSIS 
TABLE  NO.  11,  Continued. 


AUSCULTATION. 


PERCUSSION. 


HYPERTROPHY 

OF  THE 

LEFT  HEART. 


First  sound  loud,  dull,  and 
prolonged.  Aortic  second 
sound  exaggerated,  if  there 
are  no  valvular  lesions.  Ab- 
sence or  great  diminution  of 
vocal  resonance  over  a  larger 
area  than  normal,  showing 
an  enlarged  superficial  car- 
diac space.  This  sign  is  es- 
pecially available  in  females 
with  large  breasts,  where 
percussion  is  difficult. 


Extension  of  percussion 
dullness  to  the  left,  and 
wards  in  the  direction  of  the 
apex,  especially  the  latter. 
Superficial  cardiac  spat/u  in- 
cn-used  (the  lung  being  pushed 
to  the  left),  aud  greater  degree 
of  dullness  over  it  than  in 
health.  This  increase  must 
not  be  confounded  with  that 
produced  by  retraction  of  the 
lung  from  its  own  diseases. 


HYPERTROPHY 

OF  THE 
BIGHT  HEART. 


First  sound  loud,  dull,  and 
prolonged  (except  in  some 
cases  of  extensive  emphy- 
sema, where  the  edges  of  the 
lungs  by  overlapping  the 
heart  partially  muffle  the 
sound),  heard  with  greatest 
intensity  near  the  ensiform 
cartilage. 

Exaggeration  of  the  pul- 
monary second  sound,  espe- 
cially if  there  is  obstruction 
to  the  pulmonary  circula- 
tion. Auscultation  of  the 
voice  available  as  in  the 
preceding. 


Some  extension  of  dullness 
to  the  right  of  the  normal 
dullness,  but  not  in  propor- 
tion to  the  amount  of  the  en- 
largement of  the  heart,  the 
increased  area  of  dullness 
being  mostly  to  the  left. 

There  is  often  dullness  over 
the  second  and  third  right 
cartilages  near  the  sternum, 
owing  to  the  enlarged  right 
auricle. 


OF  DISEASES  OF  THE  HEART. 
TABLE  NO.  11,   Continued. 


83 


INSPECTION. 

PALPATION. 

REMARKS. 

Increased  area  of  visi- 

Apex beat  is  felt  in 

When  the  whole  heart  is 

ble   impulse,   extending 

the       sixth,      seventh, 

hypertrophied,  the  physical 

over  several  intercostal 

eighth,  or  even  ninth  in- 

signs of  left  and  right  side 

spaces    and    sometimes 

tercostal  space,  and  to 

hypertrophy  are  combined 

over  the  whole   of  the 

the    left    of    the    linea 

in  varied  proportions. 

praeconlia.     In  children 

mam  mail's,     the     down- 

In  the  great  majority  of 

there  is  often  an  abnor- 

irard displacement  being 

cases  of  cardiac  hypertro- 

mal   projection    of    the 

especially    marked.     It 

phy,  valvular  lesions  coex- 

prsecordial region.  Apex 

is  powerful  and  distinct, 

ist,  and  are  accompanied  by 

beat  sri'ii  to  be  lower  and 

though  sluggish. 

their   respective   murmurs. 

farther  to  the  left  than 

A    powerful    heaving 

When  there  are  no  valvular 

normal.     If  it  cannot  be 

movement  is  felt  all  over 

lesions,  chronic  Bright's  dis- 

seen, it  can   almost   al- 

the prascordia. 

ease   is  the  most  common 

ways  be  felt.     If  not,  it 

cause  of  left  heart  hyper- 

can be  located  by  auscul- 

trophy. 

tation. 

Increased  area  of  im- 

Apex beat  is  felt  far- 

Pulmonary    emphysema 

pulse  and  abnormal  pro- 

ther to  the  left  trenerally 

is  the  most  common  cause 

jection  as  above. 

than  in  left  side  hyper- 

of right  heart  hypertrophy, 

Strong   epigastric   im- 

trophy    (perhaps    one, 

when  there  are  no  valv  ular 

pulse,  seen  as  well  as  felt. 

two,  or  even  three  inches  :  lesions. 

often  shaking  the  lower 

to  the  left  of  the  nip-        If    the  apex   cannot  be 

part  of  the  sternum  and 

pie),  but  not  so  far  down,    felt,  its  location  can  be  as- 

extending  more  or  less 

the  lower  border  of  the    certained  by  finding  by  aus- 

over  the  liver. 

heart  being  almost  hori-    cultation  the  spot  where  the 

zontal. 

first  sound  has  the  greatest 

Apex  beat  sometimes 

intensity. 

feeble  on  account  of  the 

apex  becoming  rounded 

or  blunted.     Even  then 

there  will  be  strong  im- 

pulse in  the  intercostal 

spaces  above  the  apex. 

Powerful     heaving 

movement  all  over  the 

praecordia. 

84' 


THE  PHYSICAL  DIAGNOSIS 
TABLE   NO.   11,  Continued. 


AUSCULTATION. 


PERCUSSION. 


DILATATION  OF 
THE  HEART. 


First  sound  short,  feeble, 
and  valvular,  lacking  par- 
tially or  entirely  the  element 
of  impulsion  or  muscular 
element,  thus  resembling 
the  second  sound.  Second 
sound  often  inaudible  at  the 
apex.  Irregular  pauses,  or 
intermissions  of  the  beat, 
especially  on  exertion.  If 
a  murmur  has  previously 
existed,  its  rhythm  may 
become  lost,  and  it  may 
become  impossible  to  say 
whether  it  is  synchronous 
with  the  first  or  second 
sound.  This  is  called  asys- 
tolism. 

Respiratory  murmur  di- 
minished in  intensity  over 
the  upper  part  of  the  left 
lung. 


Area  of  dullness  is  in- 
creased in  every  direction, 
especially  laterally,  the  trans- 
verse diameter  greatly  ex- 
ceeding the  vertical.  The 
shape  of  the  dullness  is  oval 
or  square  instead  of  the  nor- 
mal triangular  dullness. 

An  upward  and  lateral  in- 
crease of  dullness  at  the  base 
of  the  enlarged  heart  indi- 
cates dilated  auricles. 


OF  DISEASES  OF  THE  HEART. 
TABLE  NO.  11,  Continued. 


85 


INSPECTION. 


PALPATION. 


The  area  of  visible 
impulse  is  increased,  but 
it  is  indistinct. 

In  persons  with  thin 
chest  walls  an  undulat- 
ing motion  over  the 
praecordia  may  be  visi- 
ble. 


Feeble  cardiac  im- 
pulse. No  heaving  move- 
ment, but  weak  undu- 
lating motion  over  the 
whole  praecordia. 

A  queer  sensation  of 
rolling  over,  a  kind  of 
diffused  tumble  against 
the  chest  walls  followed 
by  a  pause. 

Apex  beat  not  so  low 
as  in  hypertrophy. 


In  a  great  many  cases 
hypertrophy  and  dilatation 
are  combined  in  varied  pro- 
portions, so  that  we  have 
enlargement  with  predom- 
inating hypertrophy  or  en- 
largement with  predomi- 
nating dilatation.  Hyper- 
trophy precedes  dilatation 
with  rare  exceptions ;  if  the 
enlargement  be  very  great, 
dilatation  predominates. 

From  the  accompanying 
physical  signs  under  hyper- 
trophy and  dilatation,  it  can 
generally  be  determined 
which predo minates,  to 
what  extent,  and  which  side 
(if  either)  is  more  particu- 
larly affected. 

Hypertrophy  is  more  es- 
pecially the  characteristic 
of  the  left  ventricle,  and 
dilatation  of  the  right  ven- 
tricle, although  either  may 
affect  both. 


86 


THE  PHYSICAL  DIAGNOSIS 
TABLE  NO.  11,  Continued. 


DISEASE. 

AUSCULTATION. 

Rhythm  of 
Murmur. 

Maximum  Inten- 
sity of  Murmur. 

Murmur 
also  heard. 

Other  things  to 
be  noticed. 

Systolic. 

Second  right 
intercostal 

Over  the  ca- 
rotids, more  or 

Murmur  gen- 
erally soft,  but 

space,  near  the 

less    over  the 

may  be   rough 

sternum. 

body    of     the 

or  musical,  and 

VALVULAR 

heart,      some- 

it always  more 

LESIONS. 
I.  Left  Heart. 

Exceptionally 
second  left  inter- 
costal space  near 
the  sternum. 

times    in    the 
interscapul  a  r 
space  near  the 
spinous    ridge 

or      less      ob- 
scures the  first 
sound    of    the 
heart. 

of  the  scapula, 

Aortic  second 

feebly  or   not 

sound      weak- 

at  all   at  the 

ened    and     in- 

apex. 

distinct  in  pro- 

Transmitted 

portion   to  the 

better  upwards 

amount   of  ob- 

than   down- 

struction. 

wards. 

Aortic       re- 

gurgitation    is 

AORTIC  OB- 

often     asso- 

STRUCTION. 

ciuted,   when 

there  is   a  dis- 

(Stenosis.) 

tinct    double 

murmur  heard 

12.] 

over    a    large 

space. 

Numbers     in 

brackets    repre- 

sent    order     of 

frequency      ac- 

cording    to 

Walshe. 

OF  DISEASES  OF  THE  HEART. 
TABLE   NO.   11,  Continued. 


87 


PERCUSSION. 

INSPECTION. 

PALPATION. 

REMARKS. 

Hypertrophy  of 

See    Left 

See    Left 

Aortic  obstruction  is  a 

the  left  ventricle 

Heart  Hyper- 

Heart Hyper- 

very   common     form     of 

is  induced    after 

trophy     and 

trophy     and 

heart     disease.       Besides 

the      obstruction 

Dilatation. 

Dilatation. 

the  very  frequent  associa- 

has existed  for  a 

tion  of    aortic  regurgita- 

while,  and  there- 

tion, it  may  induce  after 

fore  is  found  in 

awhile  mitral  insufficiency. 

the    majority   of 

It  is  most  frequently  met 

cases  which  come 

with    in    middle     or    ad- 

under     observa- 

vanced life. 

tion. 

It  has  to  be  diagnostica- 

Finally dilata- 

ted from  an  inorganic  aortic 

tion  may  ensue. 

murmur  which  is  not  un- 

See percussion 

common  in  anaemia.   This 

signs  under  Left 

and    the    other   inorganic 

Heart   Hyper- 
trophy and  Dila- 
tation. 

murmur  —  the     pulmonic 
—  are  always  systolic. 
The  distinguishing  feat- 

ures of  the  inorganic  aortic 

murmur  are  :  — 

Uniformly  soft  and  fee- 

ble, not  constant,  not  pro- 

ductive of  cardiac  enlarge- 

ment, accompanied   by  a 

•' 

continuous  hum  in  jugular 

veins    (with   sometimes  a 

musical  intonation),  called 

"  bruit  de  dialle,"  which  is 

suspended     by     pressure 

over  the  veins  with  the  fin- 

ger, and  by  symptoms  of 

anaemia    (which   is    more 

common    among    females 

than   males)  ;    the    aortic 

second  sound  as  intense  as 

normal,  and  never  accom- 

panied by  aortic  regurgi- 

tation. 

Sometimes  there  may  be 

an  innocuous  murmur,  not 

inorganic  but  produced  by 

mere    ronr/hness   not   suffi- 

cient to  cause  obstruction, 

and  consequently  not  fol- 

lowed by  cardiac  enlarge- 

ment. 

88 


THE  PHYSICAL  DIAGNOSIS 
TABLE  NO.  11,  Continued. 


AUSCULTATION. 

DISEASE. 

Rhythm  of 

Maximum  Inten- 

Murmur 

Other  things 

Murmur. 

sity  of  Murmur. 

also  heard. 

to  be  noticed. 

Diastolic. 

Second  right 

Diffused 

Murmur  gen- 

intercostal 

over    a    large 

erally  soft,  but 

space      (or 

area,    extend- 

may  he  rough 

fourth  left  cos- 

ing in  the  di- 

or musical.     It 

tal  cartilage), 

rection  of  the 

replaces  or  im- 

AORTIC 
REGURGITA- 

near  the  ster- 
num. 

apex  or  ensi- 
form  cartilage, 
and  heard   at 

mediately    fol- 
lows the  aortic 
second    sound, 

TION. 

the     sides     of 

which  is  weak- 

(Insufficiency.) 

the  chest  and 
along  the  spine. 

ened     or    sup- 
pressed. 

f3l 

Transmitted 

Aortic   ob- 

L"'J 

hetter     down- 

struction often 

wards  than  up- 

coexists,  when 

wards. 

there  is  a  dis- 

tinct  double 

murmur  heard 

over     a    large 

space. 

Presystolic. 

At  or    near 

Over  the  su: 

Murmur  gen- 

the apex. 

perficial     car- 

erally    rough, 

diac  space 

long,  and  loud, 

only. 

sometimes 

called  "blub- 

bering ;  "     be- 

•  ginning     after 

the    second 

sound  and  end- 

MITRAL 
OBSTRUC- 

ing    abruptly 
with    the    first 

TION. 

sound. 

i 

Weakened 

(Stenosis.) 

aortic      second 

sound,  and   in- 

[*•] 

tensified     p  11  1- 

monic     second 

sound,  the  lat- 

. 

ter     owing     to 

obstruction    of 

the  pulmonary 

circulation. 

OF  DISEASES  OF  THE  HEART. 
TABLE   NO.  11,  Continued. 


89 


PERCUSSION. 

INSPECTION. 

PALPATION. 

REMARKS. 

Great    hypertrophy 

See   Left 

See    Left 

Aortic  regurgitation  is 

and  afterwards  dilata- 

Heart    Hy- 

Heart     Hy- 

more  apt  to  induce  mitral 

tion  of  the   left  ven- 

pertr o  p  h  y 

pert  r  o  p  h  y 

insufficiency    than    aortic 

tricle     are     induced. 

and   Dilata- 

and  Dilata- 

obstruction is. 

Therefore  in  the  early 

tion,      espe- 

tion,     espe- 

In such  cases  there  may 

part    of    the   disease, 

cially       the 

cially     the 

coexist  two,  three,  or  even 

the   percussion    signs 

latter. 

latter. 

all   four  of  the  murmurs 

of    the  ,  former,   and 

Strong, 

of    the  left  side  of   the 

later    those    of    both 

jerking,   ar- 

heart. 

combined,     will      be 

terial  pulsa- 

There is  generally  nei- 

found ;  finally',  if  the 

tion  felt  in 

ther  dropsy  nor  dyspnoea 

patient      lives      long 

s  u  p  e  rficial 

in  aortic   diseases,  unless 

enough,  only  those  of 

arteries    all 

mitral  regurgitation  coex- 

dilatation. 

over     the 

ists. 

body. 

Dilatation,  and  oft- 
en    hypertrophy,     of 

the  left  auricle  is  first 
produced,  followed  by 

See  Eight 
Heart     Hy- 
pertr  o  p  h  y 
and    Dilata- 

See Right 
Heart     Hy- 
pert  r  o  p  h  y 
and    Dilata- 

Mitral    obstruction     is 
comparatively  a  rare  dis- 
ease, and,  when  met  with, 
is   oftener   found    in   con- 

hypertrophy   of    the 

right  ventricle  to  over- 

tion,    espe- 
cially      the 

tion,      espe- 
cially      the 

nection  witTi  mitral  regur- 
gitation than  alone.     Still 

come  the    pulmonary 

latter. 

latter. 

it  may  exist   without   re- 

obstruction  ;  next,  dil- 

Dis t  i  n  c  t 

gnrgifation.     It  is  possible 

atation    of    the    right 

piirriiir/  thrill 

to  have  mitral  obstruction 

ventricle;   next,  dila- 

over    the 

without  a  murmur,  if  the 

tation  of  the  right  au- 

apex,     pre- 

curtains  are  not  adherent 

ricle. 

systolic     in 

at  their  sides;  and  on  the 

Finally,  not  often, 

time. 

other  hand,  Flint  says  that 

but  exceptionally,  hy- 

there   may    be,   rarely,   a 

pertrophy    or   dilata- 

mitral dir<  ct  murmur  with- 

tion of  the  left  ven- 

out obstruction  when  there 

tricle. 

is  also  free  aortic  regurgi- 

Percussion signs  ac- 

tation. 

cordingly. 

The  orifice  is  sometimes 

too  small  to  admit  the  end 

of  the  little  finger,  whereas 

in  health  t  hree  fingers  can 

be  passed  through  it. 

There  cannot  be  much 

mitral   obstruction  or  re- 

gurgitation so  long  as  the 

. 

aortic  and  pulmonic  second 

sounds  preserve  their  nor- 

mal relative  intensity. 

90 


THE  PHYSICAL  DIAGNOSIS 
TABLE  NO.  11,  Continued. 


DISEASE. 

AUSCULTATION. 

Rhythm  of 
Murmur. 

Maximum  In- 
tensity of 
Murmur. 

Murmur 
also  heard. 

Other  things 
to  be  noticed. 

Systolic. 

At  or  near 

Over   the 

Murmur  general- 

the apex. 

s  u  p  e  rficial 

ly   soft,    but  some- 

cardiac 

times  rough  or  mu- 

space ;    and 

sical. 

unless     too 

Aortic   second 

feeble,  in  the 

sound       won  ken  od, 

left      axilla 

but   pulmouic   sec- 

and behind, 

ond    sound    (heard 

near    the 

in   the    second    left 

lower  angle 

intercostal      space) 

of  the    left 

often  intensified. 

scapula. 

Where  mitral  ste- 

nosis  mid    reiMirgi- 

tation  coexist,  there 

will  lie  one  continu- 

ous murmur,  made 

up  of  two  elements, 

]'ivs\  siolic  and  sys- 

MITRAL 

tolic  ;    the    lirst    of 

REGURGITA- 

which    will    not    be 

T1ON. 

conveyed  to  the  left 

and  back.    Besides, 

(Insufficiency.) 

they  almost  always 

differ   in  pitch  and 

[1-] 

• 

quality. 

OF  DISEASES  OF   THE  HEART 
TABLE   NO.  11,  Continued. 


91 


PERCUSSION. 


INSPECTION. 


PALPATION. 


The  same 
changes  take 
place  as  in  the 
preceding ;  and 
besides,  there  is 
always  more  or 
less  hypertrophy 
or  dilatation  of 
the  left  ventricle. 
Percussion 
dullness  increased 
in  every  direction. 


Area  of  vis- 
ible impulse  in- 
creased. 


Impulse  forci- 
ble or  diffused 
according  to  the 
proportion  of  hy- 
pertrophy or  dil- 
atation. 

Apex  beat  far- 
ther to  the  left 
than  normal. 

If  hypertrophy 
predominates,  it 
will  be  lower 
than  if  dilatation 
predominates. 

Pulse  variable 
in  volume,  and  in 
the  later  stages 
also  irregular  in 
time. 


The  commonest  of. 
all  valvular  diseases, 
especially  among  th» 
young.  It  often  ex- 
ists alone,  but  may 
have  mitral  obstruc- 
tion associated  with  it. 
It  is  almost  invaria- 
bly attended  by  a 
murmur,  but  a  mitral 
systolic  non-regurgitunt 
murmur  may  be  pro- 
duced by  simple 
roughening,  c  a  1  c  a- 
reous  deposit,  etc., 
without  insufficiency 
of  the  valve.  The 
signs  which  especially 
distinguish  the  n-rjiir- 
gitant  from  the  no»-re- 
gitrc/itant  murmur  are 
the  strong  pulmonary 
second  sound,  the 
weak  aortic  second 
sound  existing  even 
with  hypertrophy  of 
the  left  ventricle,  the 
diffusion  of  the  mur- 
mur to  the  left  side 
and  to  the  back,  and, 
after  the  disea>e  has. 
made  some  progress, 
the  symptoms  of  pul- 
monary congestion. 

D  y  s  p  n  02  a  and 
dropsy  are  prominent 
symptoms  of  mitral 
obstruction  and  rc- 
gurgiration. 

Tricuspid  regurgi- 
tation  is  often  found 
as  a  secondary  affec- 
tion in  connection 
with  mitral  disease. 


THE  PHYSICAL  DIAGNOSIS 
TABLE  NO.  11,  Continued. 


AUSCULTATION. 

DISBASK. 

Rhythm   of 
Murmur. 

Maximum  In- 
tensity of 
Murmur. 

Murmur  also 
heard. 

Other  things  to 
be  noticed. 

Systolic. 

Second  or 

Propagated 

Second  pulmonic 

third  left  in- 
tercostal 

upwards  for 

a  short  dis- 

sound    impaired   ia 
iut(  nsity. 

space,   near 

t  a  n  c  e    to- 

Murmur    super- 

the sternum. 

wards      the 

ficial    and    may    be 

left  clavicle, 

quite  int.  use.   'Must 

but  not  over 

be     diagnosticated 

the  aorta  or 

from   the  / 

carotid-;. 

puimi'iiic  murmur, 

Remember 

which    is  far    more 

that   excep- 

common   than    ihe 

n.  Right 

tionally    an 

<>  r  L:  a  n  i  c.      <  it  her 

Heart. 

aortic       ob- 

alone    or   with    the 

s  t  r  u  c  t  i  v  e 

other      inorganic 

m  u  r  m  u  r 

m  u  r  m  u  r  —  t  lie 

PULMOXIC 

mat/  be  heard 

aortic  direct. 

OBSTRUC- 

with   great- 

Inorganic     mur- 

TION. 

est  inteiiMty 

murs     are     always 

at  the  second 

systolic,  and  almost 

(Stenosis.) 

or  third  left 

never  occur  except- 

i nt  ercostal 

ing:  at  the  aortic  and 

[6.] 

space.     The 

puimonic  orifices. 

frequency  of  ,       'I'  li  e     inorganic 

the       aortic      murmur  is  sot't  and 

murmur 

feeble,  with  normal 

and  its  other 

heart     sounds    and 

ch-iract  e  r  s 

no  enlargement  not 

will    gener- 

constant, occurs  in 

ally     suffice 

anaemic  persons,  es- 

for a   diag- 

pecially  yotini:   fe- 

nosis. 

males,    and    i>    ac- 

companied   by    ihe 

bruit  de  diaile. 

Diastolic. 

Second  or 

Propagated 

Pnlmonic  second 

third  left  in-  !  downwards 

sound    impaired   in 

tercosta  1 

towards  the 

intensify. 

PULMONIC 

space,    near 

e  n  s  i  f  o  r  m 

This  murmur    if 

REGCRGITA- 

the  sternum. 

cartilage. 

it  were    more  com- 

TION. 

mon,   might   easily 

be  confounded  with 

(Insufficiency.) 

an    aortic    regurgi- 

tant  murmur,  when 

[7-] 

the.  pulmonary    di- 

rect    murmur     did 

not  co-exist. 

OF  DISEASES  OF  THE  HEART. 
TABLE  NO.  11,  Continued. 


PERCUSSION. 


INSPECTION. 


PALPATION. 


Hyper  trophy 
and  dilatation  of 
the  right  ventri- 
cle are  produced. 

Percussion 
signs'  accordingly. 


See  Hyper- 
trophy and  Dil- 
atation of  the 
Right  Ventricle. 


See  Hyper- 
trophy and  Dil- 
atation of  the 
Right  Ventricle. 


Valvular  diseases  of 
the  right  heart,  \\ith 
the  exception  of  tri- 
cuspid  regurgitation, 
are  so  infrequent  as 
to  be  almost  unheard 
of  ;  so  much  'so,  ihat 
when  the  unqualified 
term  "  valvular  dis- 
ease "  is  used,  the  left 
heart  is  always  meant. 

When  right-heart 
lesions  exist,  they  are 
usually,  but  not  inva- 
riably, associated  with 
left-heart  lesions,  un- 
less they  are  congen- 
ital. 

Contrary  to  the  rule 
which  prevails  after 
birth,  the  right  luart 
is  more  commonly  af- 
fected in  praenatal  life 
than  the  left. 


Theoretically, 
hypertrophy  and 
dilatation  of  the 
right  ventricle 
are  produced. 

Percussion 
signs  accordingly. 


See  Hyper- 
trophy and  Dil- 
atation of  the 
Right  Ventricle. 


See  Hyper- 
trophy and  Dil- 
atation of  the 
Right  Ventricle. 


Pulmonic  regurgi- 
tation  is  exceKlimjl;/ 
rare,  even  more  so 
than  pulmonic  ob- 
struction. C  O  II  S  ('- 
quently,  the  annexed 
physical  signs  of  it 
are,  to  a  great  extent, 
theoretical. 

Tricuspid  insuffi- 
ciency may  follow 
pulmonic  obstruction 
or  regurgitation. 


THE  PHYSICAL  DIAGNOSIS 
TABLE   NO.  11,  Continued. 


AUSCULTATION. 

DISEASE* 

Rhythm   of 
Murmur. 

Maximum  In- 
tensity of  Mur- 
mur. 

Murmur  also 
heard. 

Other  things  to  be 
noticed. 

4 

TRICUSPID 
OBSTRUCTION. 

Presystolic. 

At   lower 
part  of  ensi- 

form    carti- 

(Stenosis.) 

lage. 

[8.] 

Systolic. 

At   lower 

Generally 

A  murmur  is  not 

part  of  ensi- 

limited   to 

present   i  n    in  a  n  y 

forrn    carti- 

the  superfi- 

cases of  actual  tri- 

lage. 

cial  cardiac     cuspid   regurg  i  t  a- 

space. 

tion,    even    when 

TRICUSPID 

If    trans- 

there   is   a  definite 

REGURGITA- 

mitt  ed  at 

valvular     lesion. 

TION. 

all,  it  is  to 

Rarely,    if    ever, 

r 

the  right. 

rough. 

(Insufficiency.) 

Pulmonic  second 

sound  diminished  in 

[5.] 

intensity.    Mitral 

or  aortic  murmurs, 

or  both,  often  coex- 

ist, differing  in  pitch 

and  quality. 

OF  DISEASES  OF  THE  HEART. 
TABLE  NO.  11,  Continued. 


95 


PERCUSSION. 

INSPECTION. 

PALPATION. 

REMARKS. 

Theoretically, 

The  rarest  of  all. 

hypertrophy  and 

dilatation  of  the 

right  auricle  are 

first  produced. 

First  the  right 
auricle  is  dilated, 

Jugular    pul- 
sation,   synchro- 

Indistinct apex 
beat  unless  there 

Primary     tricuspid 
regurgitation  is  very 

then    the    right 

nous    with     the 

is   considera  b  1  e 

rare;    but   secondary 

ventricle    is   hy- 

heart's  systole,  — 

hypertrophy    o  f 

to   mitral  stenosis  or 

pertrophied   and 

a    characteristic 

the  left  ventricle. 

regurgitation,     it     is 

dilated.     Then 

sign  of  tricuspid 

Distinct    e  p  i- 

not  uncommon. 

comes     enlarge- 

regurgi t  a  t  i  o  n, 

gastric   p  u  1  s  a- 

It  not  infrequently 

ment  of  the  left 

unless  the  right 

tion. 

exists  in  cases  where 

ventricle   on  ac- 

ventricle be  very 

there  is  no  definite  le- 

count of  its   in- 

weak from  dila- 

sion of  the  valve,  but 

creased  work. 

tation. 

where,  on  account  of 

Per  c  u  s  s  i  o  n 

Larger  area  of 

enlargement    of     the 

signs   accord- 

visible     impulse 

right  heart  from  mit- 

ingly. 

than    with    any 

ral  disease,  the  tricus- 

other valvular 

pid  orifice  is  enlarged 

lesion. 

without  a  proportion- 

ate   enlargeme  n  t  o  f 

the  valve. 

96 


THE  PHYSICAL  DIAGNOSIS 
•  TABLE  NO.  11,  Continued. 


AUSCULTATION. 


PERCUSSION. 


FATTY  DEGEN- 
ERATION OF  THE 
HEABT. 


Both  heart  sounds  are  per- 
manently weakened,  especially 
the  Jirst.  The  second  sound 
over  the  apex  is  clearer  and 
louder  than  the  first.  First 
sound  often  absent.  When 
present,  it  is  short  and  valvu- 
lar, the  muscular  element  or 
element  of  impulsion  being 
greatly  impaired.  This  con- 
dition is  pemstent,  not  tempo- 
rary; and  several  examina- 
tions must  be  made  before  de- 
ciding on  the  diagnosis. 


Normal  area  of  dullness 
as  a  rule. 

Sometimes  a  dilated  or 
hypertrophied  heart  un- 
dergoes fatty  degenera- 
tion, when,  of  course,  its 
increased  area  of  dullness 
will  remain. 


CABDIAC  NEUBO- 

8E8. 

(Nervous     or    func- 
tional disorders  of 
the  heart.) 


Heart  sounds  healthy  in 
quality,  but  intensified,  clearer, 
and  more  abrupt  than  normal. 
Occasionally  the  first  sound  is 
metallic,  and  either  may  be  re- 
duplicated. 

An  inorganic  anaemic  mur- 
mur is  sometimes  heard  at  the 
base  of  the  heart.  It  is  systolic, 
either  aortic  or  pulmonic  or 
both,  soft  and  feeble,  often 
propagated  into  the  carotids, 
and  accompanied  by  a  hum  in 
the  veins  of  the  neck. 


Percussion  dullness  nor- 
mal. 

As  a  mere  coincidence, 
functional  disease  may  ex- 
ist in  a  hypertro  p  h  i  e  d 
heart. 


OF  DISEASES  OF  THE  HEART. 
TABLE   NO.  11,  Continued. 


97 


INSPECTION. 


PALPATION. 


No  visible  im- 
pulse as  a  rule, 
even  in  thin  per- 
sons. 

If  there  is  any, 
it  is  very  indis- 
tinct. 


Very  little  or  no  apex 
beat  can  be  felt.  If  felt 
it  is  generally  in  its  nor- 
mal position,  and  is  irreg- 
ular or  intermittent. 

If  a  hypertrop  hied 
heart  becomes  fatty,  there 
is  a  tumbling,  rolling  mo- 
tion. 


Valvular  lesions  may  co-exist. 
The   diagnosis   of    fatty   de- 
generation of  a  hypertrophied 
heart  is  very  difficult. 


Increased  area 
of  visi  b  1  e  i  m- 
pulse,  which  may 
be  seen  to  be  ir- 
regular and  in- 
termittent at 
times. 


Apex  beat  in  normal  po- 
sition. 

Increased  action,  not 
power.  Beat  abrupt  and 
brief.  A  violent  blow, 
not  a  powerful  heaving. 

Sometimes  impulse 
weaker  than  natural. 


The  physical  signs  are  both 
negative  and  positive,  —  nega- 
tive in  excluding  all  organic 
disease,  and  positive  in  show- 
ing the  healthy  size,  position, 
and  sounds  of  the  heart. 

Patients  with  functional  dis- 
ease complain  much  more  of 
heart  symptoms  than  those  with 
organic  disease.  Inorganic  pal- 
pitation is  increased  by  seden- 
tary life,  organic  by  exercise. 


INDEX. 


-35gophony,  44. 
Amphoric  respiration,  28. 

percussion  resonance,  50. 

voice,  44. 

whisper,  44. 
Anaemic  murmurs,  87. 
Aneurism,  76. 
Aortic  obstruction,  86. 

regnrgitation,  88. 
Asthma,  64. 

Bronchial  rales,  30. 

respiration,  26. 

whisper,  normal,  40. 

increased,  42. 
Bronchiectasis,  74. 
Bronchitis,  acute  and  chronic,  64. 

capillary,  66. 

plastic  or  pseudo-membranous,  66. 
Broncho-cavernous  respiration,  28. 

vesicular  respiration,  26. 

pneumonia,  70. 
Bronchophony,  42. 

whispering,  42. 
Bubbling  rales,  32. 

Capillary  bronchitis,  66. 
Cardiac  neuroses,  96. 
Carcinoma  of  lung,  76. 
Catarrhal  pneumonia,  70. 
Cavernous  rales,  34. 

respiration,  28. 

whisper,  44. 

Clicking.     See  SIBILANT  RALES,  30. 
Cogged-wheel  respiration,  24. 
Cracked-metal  resonance,  50. 
Crackling.    See  CREPITANT  RALES,  34. 
Crepitaut  rales,  34. 
Croupous  pneumonia,  68. 


Dilatation  of  the  bronchi,  74. 

heart,  84. 
Diminished  vocal  fremitns,  42. 

resonance,  42. 
Dry  or  vibrating  rales,  30. 
Dullness  on  percussion,  46. 

Emphysema,  62. 

Empyema,  56. 

Endocarditis,  80. 

Exaggerated  percussion  resonance,  50. 

respiration,  28. 
Expiration  prolonged,  24. 

Fatty  degeneration  of  the  heart,  96. 
Feeble  respiration,  22. 
Fibroid  phthisis,  70. 
Fine  bubbling  rales,  32. 
Flatness  on  percussion,  46. 
Fremitus,  diminished  vocal,  42. 

increased  vocal,  42. 

suppressed  vocal,  42. 
Friction  sounds,  36. 

Gurgling  rales,  34. 

Harsh  respiration,  26. 
Healthy  heart,  78. 
Hippocratic  succussion  sound,  38. 
Hydro-pericardium,  81. 
Hydrothorax,  58. 
Hypertrophy  of  the  left  heart,  82. 
right  heart,  82. 

Increased  bronchial  whisper,  42. 

respiration,  22. 

vocal  fremitus,  42. 

vocal  resonance,  42. 
Inorganic  murmurs,  87. 


100 


INDEX. 


Insufficiency,  aortic,  86. 

mitral,  90. 

pulmonic,  92. 

tricuspid,  94. 
Intercostal  neuralgia,  25. 
Interrupted  respiration,  24. 
Interstitial  pneumonia,  70. 
Intra-thoracic  tumors,  76 . 

Jerking  respiration,  24. 

Laryijgeal  rales,  30. 

respiration,  20. 

voice,  40. 

Laryngophony,  40. 
Left-heart  hypertrophy,  82. 

valvular  lesions,  86. 
Lobar  pneumonia,  acute,  68. 
Lobular  pneumonia,  70. 

Metallic  tinkling,  36,  44. 
Miliary  tuberculosis,  72. 
Mitral  obstruction,  88. 
regurgitation,  90. 
Moist  rales,  30. 
Morbid  pleural  sounds,  36. 
Mucous  rales,  32. 

Nervous  diseases  of  the  heart,  96. 
Neuralgia,  intercostal,  25. 
Neuroses,  cardiac,  96. 
Normal  bronchial  whisper,  40. 

thoracic  vocal  resonance,  40. 

vesicular  percussion  resonance,  46. 

vesicular  respiration,  20. 

(Edema,  pulmonary,  58. 
Obstruction,  aortic,  86. 

mitral,  88. 

pulmonic,  92. 

tricuspid,  94. 

Pectoriloquy,  44. 

whispering,  44. 
Pericarditis,  78. 
Phthisis,  72. 
Plastic  bronchitis,  66. 
Pleurisy,  acute,  54. 

chronic,  56. 
Pleurodynia,  25. 


Pneumo-hydrothorax,  60. 
Pneumonia,  acute  lobar,  68. 

catarrhal,  66,  70. 

chronic,  70. 
Pneumothorax,  62. 
Prolonged  expiration,  24. 
Puerile  respiration,  20,  22. 
Pulmonary  oedema,  58. 

percussion  resonance,  46. 

respiration,  20. 
Pulmonic  obstruction,  92. 

regurgitation,  92. 

Kales,  bronchial,  30. 

bubbling,  coarse,  32. 

bubbling,  fine,  32. 

cavernous,  34. 

clicking.     See  SIBILANT,  30. 

crackling.     See  CKEPITANT,  34. 

crepitant,  34. 

dry,  30. 

gurgling,  34. 

laryngeal,  30. 

moist,  30. 

mucous,  32. 

sibilant,  30. 

sonorous,  30. 

sub-crepitant,  32. 

tracheal,  30. 

vesicular,  34. 
Regurgitation,  aortic,  88. 

mitral,  90. 

pulmonic,  92. 

tricuspid,  94. 

Resonance  on  percussion,  absence    of, 
46. 

amphoric,  50. 

cracked-metal,  50. 

diminished,  46. 

exaggerated,  50. 

normal  vesicular,  46. 

pulmonary,  46. 

tympanitic,  48. 

vesiculo-tympanitic,  50. 
Resonance,  vocal,  diminished,  42. 

increased,  42. 

normal  thoracic,  40. 

suppressed,  42. 
Respiration,  absence  of,  22. 

amphoric,  28. 


INDEX. 


Respiration,  bronchial,  26. 

broncho-cavernous,  28. 

broncho-vesicular,  26. 

cavernous,  28. 

cogged-wheel,  24. 

feeble,  22. 

harsh,  26. 

healthy,  20. 

increased,  22. 

interrupted,  24. 

jerking,  24. 

laryngeal,  20. 

puerile,  20,  22. 

pulmonary,  20. 

rough,  26. 

rude,  26. 

senile,  22. 

suppressed,  22. 

tracheal,  20. 

tubular,  26. 

tubule-vesicular,  26. 

vesicular,  26. 

vesiculo-bronchial,  26. 

wavy,  24. 

weak,  22. 
Eight-heart  hypertrophy,  82. 

valvular  lesions,  92. 

Sibilant  rales,  30. 
Sonorous  rales,  30. 
Splashing,  38. 
Stenosis,  aortic,  86. 

mitral,  88. 

pulmonic,  92. 

triru?pid,  94. 
Sub-crepitant  rales,  32. 
Suppressed  respiration,  22. 

vocal  resonance,  42. 


Tinkling,  metallic,  36,  44. 
Tracheal  rales,  30. 

respiration,  20. 

voice,  40. 

whisper,  40. 
Tracheophony,  40. 

whispering,  40. 
Tricuspid  obstruction,  94. 

regurgitation,  94. 
Tuberculosis,  acute  miliary,  72. 
Tubular  respiration,  26. 
Tubulo-vesicular  respiration,  26. 
Tympanitic  resonance,  48. 

Valvular  lesions,  86. 
Vesicular  rales,  34. 

respiration,  20. 

resonance  on  percussion,  46. 
Vesiculo-tympanitic  resonance  on  per- 
cussion, 50. 

Vesiculo-bronchial  respiration,  26. 
Vibrating  rales,  30. 
Vocal  resonance,  diminished,  42. 

increased,  42. 

normal  thoracic,  40. 

suppressed,  42. 
Voice  in  disease,  42. 

laryngeal,  40. 

tracheal,  40. 

Wavy  respiration,  24. 
Weak  respiration,  22. 
Whispering  bronchophony,  42. 

pectoriloquy,  44. 

tracheophony,  40. 
Whisper,  amphoric,  44. 

cavernous,  44. 

tracheal,  40. 


3  1970  00592  4623 


SOUTHERN  REGIONAL  LIBRARY  FACIUTY 


A  000  501  566 


WB278 

C589t 
1885 

Glapp.  Herbert  C 

Tabular  handbook  of  auscultation  and 
oercussion. 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


